Director Conflict of Interest Form

When to use this

Required by governance code in most jurisdictions. Captures direct interests, indirect interests (family / close associates), and any potential conflict the director wants to flag pre-emptively.

What’s included

• 1. Other directorships and external roles
• 2. Material shareholdings (≥ 1% in a listed company, or any holding in an unlisted entity that could create a conflict)
• 3. Family / close associate interests
• 4. Any other actual, potential, or perceived conflicts
• 5. Declaration

What to customise before you use it

• Replace Company name with your real meeting, project, or stakeholder details.
• Replace Year with your real meeting, project, or stakeholder details.
• Replace Free text with your real meeting, project, or stakeholder details.
• Replace Date with your real meeting, project, or stakeholder details.

# Director Conflict of Interest Declaration

**Director name:** _____________________________
**Company:** [Company name]
**For the year:** [Year]

## 1. Other directorships and external roles
Please list all current external directorships, trusteeships, partnerships, and material employment relationships.

| Organisation | Role | Date appointed | Listed / private | Sector |
|--------------|------|----------------|-------------------|--------|
|              |      |                |                   |        |

## 2. Material shareholdings (≥ 1% in a listed company, or any holding in an unlisted entity that could create a conflict)

| Company | % held | Nature |
|---------|--------|--------|
|         |        |        |

## 3. Family / close associate interests
Please list any role or interest held by a close family member or business associate that could be perceived as a conflict.

| Person | Relationship | Role / interest |
|--------|--------------|------------------|
|        |              |                  |

## 4. Any other actual, potential, or perceived conflicts

> [Free text]

## 5. Declaration

I confirm the above is a true and complete declaration as at [Date], and I undertake to notify the Company Secretary in writing within 5 working days of any change.

**Signed:** ____________________   **Date:** _____________

(Stored confidentially by the Company Secretary; reviewed annually.)