Pecuniary Interests Declaration Form
Please complete this form to declare any financial interests or relationships that may present a conflict of interest.
Full Name
*
First Name
Last Name
Position or Role
*
Department or Organization
*
Email Address
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Declaration Period
*
Please Select
Current Year
Past 12 Months
Other (please specify below)
Do you, your spouse/partner, or close family members hold any shareholdings or ownership interests in organizations that may interact with your department/organization?
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Yes
No
If yes, please provide details of shareholdings or ownership interests (organization name, nature of interest, relationship to you). If no, write 'N/A'.
*
Do you or your close family members hold any directorships, board memberships, or paid positions with external organizations?
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Yes
No
If yes, please provide details of directorships or paid positions (organization, position, relationship to you). If no, write 'N/A'.
*
Have you or your close family members received any gifts, hospitality, or benefits from external organizations or individuals in the last 12 months?
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Yes
No
If yes, please provide details of gifts, hospitality, or benefits (nature, value, source, date). If no, write 'N/A'.
*
Do you have any external employment, consultancy, or business interests that may relate to your role?
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Yes
No
If yes, please provide details of external employment or business interests (organization, nature of work, relationship to your role). If no, write 'N/A'.
*
Are there any other pecuniary interests, relationships, or circumstances that could be perceived as a conflict of interest?
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Yes
No
If yes, please provide details. If no, write 'N/A'.
*
Signature (please sign below to confirm your declaration)
*
Submit Declaration
Submit Declaration
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