Declaration of a Conflict of Interest

Personal details

Company*

Name*

Surname*

Job title / area of responsibility*

Email address*

Phone number*

An actual, potential, or perceived conflict of interest has been identified within my company.*

Yes

No

The actual, potential, or perceived conflict of interest relates to*

Please elaborate*

The following actual, potential, or perceived conflict of interest has been identified:*

Insert all relevant details and upload supporting documentation, if needed

Supporting documents

Drop files here or click to browse.

The conflict is expected to last for:*

0–12 months

More than 12 months or indefinitely

In my opinion, the details above:*

do not constitute a conflict of interest, and I authorise the employee to continue the activity.

do constitute an actual, potential, or perceived conflict of interest.

If the situation does constitute a conflict of interest, please ensure that the following actions have been considered:

Ensure all information surrounding the conflict has been disclosed to DFA and documented.
Inform likely affected persons in both DFA and your company (or any subcontractor that you employ to work on DFA projects) of the conflict and request their views where relevant as to whether they object.
Reformulate the scope of work or restricting access to certain information.
Recruit a third party to oversee part or all of the process at the cost of the conflicted party.
Recommend relinquishing the interest that is causing the conflict.
Temporarily remove the person from the process or responsibilities by which conflict is arising.
Monitor the person’s activities closely in relation to the possible conflict of interest.
Take no further action because the conflict is deemed as reasonably minimal by all parties involved.

I have reviewed the above considerations and request that the Employee takes the following action to eliminate/manage the conflict:*

I will ensure this action plan is reviewed:*

Explain the alternative review period:*

By signing and submitting this form, I agree to the following:

To the best of my knowledge and belief, any actual, perceived or potential conflicts between my duties as a supplier and the supplier's business interests with DFA have been fully disclosed in this form in accordance with the requirements of the DFA Code of Conduct, Code of Ethics, and Gift Policy.
If a conflict has been identified:
- I acknowledge and agree to comply with any approach identified in this form for removing or managing an actual, perceived, or potential conflict of interest.
- The actions described in the approach outlined in the action plan above have been put in place to effectively manage any actual, potential or perceived conflict of interest. The approach ensures that DFA’s public interests and reputation is adequately protected.
I confirm that I am duly authorized to complete and sign this disclosure.

Signature*

Name and surname*

Date*