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SCHEDULE B
Declaration of Conflict of Interest Form – Business Association or Personal Conflict
Originator's Name:
Originator's Position/Title:
Department reporting to:
Name of company(s) &/or individual(s) involved with the actual or potential conflict of interest:
I hereby declare the following actual or potential conflict of interest (describe in detail and attach additional
materials as required):
This section to be completed with an Officer of OUC (the "Approving Officer")
As a result from discussions with the Approving Officer, the following actions are to be taken or measures are to be
put in place to mitigate the actual or potential conflict of interest (if any):
☐
Originator
(name of the person making the declaration) must refrain from performing or getting
involved in performing the work/duty, as described above, which may give rise to a conflict.
☐
Originator
(name of the person making the declaration) may continue to handle the work/duty as
described in above, provided that there is no change in the information declared above.
☐
Other/Comments
– Specify and be specific:
Originator (Required):
DD/MM/YYYY
Signature
: ______________________________________________________ Date:
/
/
Name:
Title:
Department:
Approving Manager (Required):
DD/MM/YYYY
Signature
: ______________________________________________________ Date:
/
/
Name:
Title:
Approving Officer (Required):
DD/MM/YYYY
Signature
: ______________________________________________________ Date:
/
/
