Instructions:- Noted by the company. To be reviewed in (fill in as below) months intervals- Giving up the interest or terminating the relationship- Realignment of employment or job function- Termination of employment
To be reviewed in ___ months intervals: ____________
Authorized person: ____________
Authorized person Title: ____________
Date (YY/MM/DD format): ____________
Relationship with company:
Competitor
Supplier
Contractor
Customer
Other ( please specify)
I and/or an immediate family member have the following financial and / or other interests which may conflict with the business of the Company:
I and/or an immediate family member have no financial and / or other interests which may conflict with the business of the Company.