Declaration of Interest Template for Sport & Active ... - VicSport
Declaration of Interest Template for Sport & Active ... - VicSport
Declaration of Interest Template for Sport & Active ... - VicSport
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<strong>Declaration</strong> <strong>of</strong> <strong>Interest</strong> <strong>Template</strong> <strong>for</strong> <strong>Sport</strong> &<strong>Active</strong> Recreation Clubs<strong>Declaration</strong> <strong>of</strong> Private <strong>Interest</strong>I, (insert full name)……………………………………………………………<strong>of</strong> (insert name <strong>of</strong> organisation)………………………………………….…declare my private interests as at (date)………………………………..…1. Other substantial sources <strong>of</strong> income:Do you receive income apart from yourmain source <strong>of</strong> income, that couldreasonably raise an expectation <strong>of</strong> aconflict <strong>of</strong> interest with your duties in thisrole?(Circle yes or no as appropriate)No.Yes. Please list.2. Office holder:Do you hold <strong>of</strong>fice in a public or privatecompany, or other body, includingcommunity or other not-<strong>for</strong>-pr<strong>of</strong>itorganisation(s), that could reasonably raisean expectation <strong>of</strong> a conflict <strong>of</strong> interest withyour duties in this role?(Circle yes or no as appropriate)No.Yes. Please list and advise <strong>of</strong> potentialconflict.3. Trusteeships:Are you a trustee or a Director <strong>of</strong> anytrustee company in which a member <strong>of</strong> yourimmediate family is a beneficiary, that couldreasonably raise an expectation <strong>of</strong> aconflict <strong>of</strong> interest with your duties in thisrole?(Circle yes or no as appropriate)No.Yes. Please list and advise <strong>of</strong> potentialconflict.Victoria's Peak <strong>for</strong> <strong>Sport</strong> & <strong>Active</strong> RecreationLevel 3, <strong>Sport</strong>s House, 375 Albert Rd, South Melbourne VIC 3205T +61 3 9926 1376 I E: admin@vicsport.asn.auF +61 3 9696 7931 I W: www.vicsport.asn.au
4. Agreements:Are you, or a member <strong>of</strong> yourimmediate family, party to any contract,agreement or understanding that givesrise to an obligation or an expectation<strong>of</strong> reward (<strong>for</strong> example an agreementregarding future employment) thatcould reasonably raise an expectation<strong>of</strong> a conflict <strong>of</strong> interest with your dutiesin this role?5. Other interests:Do you, or any member <strong>of</strong> yourimmediate family, hold any othersubstantial financial or other interestthat could reasonably raise anexpectation <strong>of</strong> a conflict <strong>of</strong> interest withyour duties in this role?(Circle yes or no as appropriate)No.Yes. Please list and advise <strong>of</strong> potentialconflict.(Circle yes or no as appropriate)No.Yes. Please list and advise <strong>of</strong> potentialconflict.6. Director’s duties:Have you ever been disqualified fromacting as a Director, or acting in themanagement <strong>of</strong> a company?(Circle yes or no as appropriate)No.Yes. Please list.I am aware <strong>of</strong> the conflict <strong>of</strong> interest policy and my obligations under it. I declare that to the best <strong>of</strong> my knowledge, thein<strong>for</strong>mation I have provided is true and correct. I undertake to advise in writing if a conflict or potential conflict arises in the future, and to stand down inany decision making process in which I may be compromised.If there is any change to the interests set out in this document I undertake to advise <strong>of</strong> any alterations or additions to my declaration as soon as possible.Signature <strong>of</strong> Declarant……..…………………………………………………………Position …………………………………………………………………………….…..…Date:……………………………………………………………………………………….…….…..Signature <strong>of</strong> Witness………………………………………………………………………Position ……………………………………………..………………………….…………Date: ………………………………………………………………………………….…Victoria's Peak <strong>for</strong> <strong>Sport</strong> & <strong>Active</strong> RecreationLevel 3, <strong>Sport</strong>s House, 375 Albert Rd, South Melbourne VIC 3205T +61 3 9926 1376 I E: admin@vicsport.asn.auF +61 3 9696 7931 I W: www.vicsport.asn.au