Private and staff-in-confidence

Disclosure of Relevant
Personal Interests Form

Employee[or insert other title]

Name
Role
Date of disclosure

Please note

You need to disclose those interests held by you, your partner, dependents or close associates about which you have knowledge and that you consider may have a bearing, or be perceived to have a bearing, on your ability to properly and impartially discharge your duties. If in doubt, discuss with your manager.

Sections of the form that are not relevant to the disclosure of your interests should be left blank.

Information about your pecuniary and non-pecuniary interests is being collected in accordance with our Code of Conduct and Conflict of Interests policy in order to aid in the recognition of actual or potential conflict of interest (real or perceived). The information will be accessible only by you and [Agency head or principal officer] and their delegate. Your information will not be given to any other person or agency unless you give permission or it is required by law.

Shareholdings in public and private companies

Self, partner, dependent or close associate / Name of company / Shares held

Family and business trusts and nominee companies

Self, partner, dependent or close associate / Name of trust/nominee company / Units/holding

Bonds, debentures and like investments

Self, partner, dependent or close associate / Type of investment / Investment body

Partnerships

Self, partner, dependent or close associate / Name of partnership / Nature of interest

Real estate

Self, partner, dependent or close associate / Location (address) / Nature/share of interest

Directorship in or employment by a public or private company:

Self, partner, dependent or close associate / Name of company / Position held

Position in trade union / professional, business, sporting or voluntary associations:

Self, partner, dependent or close associate / Name of organisation / Position held

Other interests that should be disclosed:

Self, partner, dependent or close associate / Description of interest / Relevance

Other information which may be of assistance:

Liabilities:

Self, partner, dependent or close associate / Nature of liability / Creditor
Employee [or other title]certification:
I certify that:
a)The information provided in this form properly reflects, to my knowledge, my interests and/or the interests of my partner, dependents or close associates that may have a bearing, or be perceived to have a bearing, on my ability to properly and impartially discharge my duties; and
b)The information is provided to meet the requirements of our Code of Conductand Conflict of Interests policy; and
c)A copy of this form will be provided to [Agency head or principal officer]delegate; and
d)I understand that if there is a change to the interests after giving this form, I shall provide a Variation of Interests form within 14 days; and
e)I understand that if particular conflictsof interests arise my employmentI will disclose such conflictsin accordance with our Conflict of Interests policy.
Signature of employee
Date

Agency name | Disclosure of Relevant Personal Interests Form1