If the answer to the question right above is Yes, then more information and my signature are as below:
Name of the organization involved: ____________
Estimated value of the financial interests: ____________
Part B: To be completed by MD / Compliance committee / … in case of conflict(s) of interest declared
Signature of Authorized person
Nature of the financial interests:
Ownership
Partnership
Shareholder
Consultancy
Part-time job
Other (please specify)
I and/or an immediate family member have no financial and / or other interests which may conflict with the business of the Company.