Conflict of Interest Declaration Form - Template Form

________ (the "Company")

CONFLICT OF INTEREST DECLARATION FORM

Name of employee: ________

Job title/position: ________

Email: ________

Phone: ________

DECLARATION

I, ________, of ________, do hereby declare and undertake as follows:

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• That I will not engage in any transaction that will cause a potential conflict of interest or financial interest or potential gain in the transaction of the Company.
• That I shall not be involved in the recruitment, promotion, or appointment of a close relative without disclosing such matter to management.
• That I will not engage in a transaction or activity that conflicts with the interests or objectives of this Company.
• That I will not use or misappropriate the Company's confidential or trade secret information for personal gain or benefit.
• That I will not operate, manage, or otherwise be involved in a business that directly competes with the business of the Company.

That I will not accept a substantial monetary or other gift and not disclose it to the Company.

Notwithstanding the above, the aforementioned declaration, I hereby disclose the following actual or potential conflict of interest:

________

I undertake not to let my actions or interest be impeded by any personal gain or benefit.

I undertake to avoid any future transaction, dealings, or relationship that may prejudice my fiduciary duties or commitment to the Company.

ACKNOWLEDGEMENT

I acknowledge that I have carefully reviewed this form and I confirm that the information provided herein is true, correct, and complete to the best of my knowledge.

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SIGNED, DECLARED, AND ACKNOWLEDGED by the Employee:

Name of Employee:......................................................................................

Date of Receipt:............................................................................................

Signature of Employee:................................................................................