THIS TEMPLATE IS FOR DEMONSTRATION PURPOSES ONLY AND SERVES AS SAMPLE. DISTRIBUTOR IS RESPONSIBLE TO ENSURE THAT THE TEMPLATE IS IN ACCORDANCE WITH ALL LOCAL REQUIREMENTS BEFORE USE

CONFLICT OF INTEREST (COI) - DISCLOSURE FORM

INSTRUCTIONS

Customize this document according to your company’s needs; Ensure this or similar document is accessible to all employees, including officers, directors, employees and all relevant business partners, such as sub distributors and agents; Ensure employees understand their duties and responsibilities as it relates to your company’s commitment to ethical and lawful conduct; Train your employees on this form and keep training records.

Note: A conflict of interest occurs when a person’s private interest interferes or could interfere in any way with the Company’s interests. For example, a conflict of interest may arise when an employee, director, or a member of his or her family receives improper benefits because of his or her position within the Company. Any potential conflict of interest should be declared below.

EMPLOYEE INFORMATION
Name	Title / role
Function	Date of awareness of COI
Manager Name	Manager Title
POTENTIAL CONFLICT OF INTEREST DESCRIPTION
Tick the appropriate box to classify the COI	☐ Outside employment ☐ Personal relationships ☐ Financial interests ☐ Other (describe below) ☐ Gifts and hospitality
Describe the specific situation that you believe to be a COI
RESOLUTION
This potential conflict of interest was confirmed	☐ Yes ☐ No
If yes, describe the agreed remediation plan
Employee Signature Date	HR / Employee Manager Signature Date