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
Agency name | Disclosure of Relevant Personal Interests Form
Shares held
1
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
Name of partnership
Nature of interest
Location (address)
Nature/share of interest
Partnerships
Self, partner, dependent or
close associate
Real estate
Self, partner, dependent
or close associate
Directorship in or employment by a public or private company:
Self, partner, dependent or
close associate
Name of company
Agency name | Disclosure of Relevant Personal Interests Form
Position held
2
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
Agency name | Disclosure of Relevant Personal Interests Form
Creditor
3
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 Conduct and 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 conflicts of interests arise my employment I will disclose such conflicts in
accordance with our Conflict of Interests policy.
Signature of employee
Date
Agency name | Disclosure of Relevant Personal Interests Form
4