Pro Forma Interests and Conflict Declaration Sheet for Panel Members
This pro-forma is to assist Panel Members and the President consider their potential conflicts in relation to a matter on which the member may be asked to sit.
This pro-forma is not exhaustive of all possible avenues or sources of conflict. Members should consider what other possible sources or avenues of conflict might exist in relation to each individual matter.
Where there are a number of interested third parties, these have been separately identified to assist members in considering conflicts involving those parties.
The time frame for disclosure of securities trading is an estimate of what might be considered a material period. If it does not appear appropriate for the particular case, matter or circumstances use a time frame which appears most appropriate.
To the extent you are able, every possible interest that might cause a conflict, or perception of conflict, should be disclosed. The ASIC Act places the onus on the President to determine which interests are not material, rather than individual members.
Member's Name:
Organisation/s:
Relationship:
Previous Work History (last 5 years):
Target:
Personal business relationship/work performed for Target:
Firm's business relationship with Target:
Personal business relationship/work performed for Target parent, sibling or subsidiary entities:
Firm's business relationship with Target parent, sibling or subsidiary entities:
Personal relationship, business or other, with directors of Target or related entities:
Firm's business relationship with Target or related Directors:
Personal shareholding in Target or related entities (describe size and value of holding; direct or indirect ownership and control of the holding; date acquired; proportion of your portfolio etc):
Personal Trading in Target or related entities' securities (last 12 months):
Firm's shareholding in Target or related entities:
Bidder:
Personal business relationship/work performed for Bidder:
Firm's business relationship with Bidder:
Personal business relationship/work performed for Bidder parent, sibling or subsidiary entities:
Firm's business relationship with Bidder parent, sibling or subsidiary entities:
Personal relationship, business or other, with directors of Bidder or related entities:
Firm's business relationship with Bidder or related Directors:
Personal shareholding in Bidder or related entities (describe size and value of holding; direct or indirect ownership and control of the holding; date acquired; proportion of your portfolio etc):
Personal Trading in Bidder or related entities' securities (last 12 months):
Firm's shareholding in Bidder or related entities:
Interested Third Party:
Personal business relationship/work performed for Interested Third Party (identify the party):
Firm's business relationship with Interested Third Party:
Personal business relationship/work performed for Interested Third Party parent, sibling or subsidiary entities:
Firm's business relationship with Interested Third Party parent, sibling or subsidiary entities:
Personal relationship, business or other, with Directors of Interested Third Party or related entities:
Firm's business relationship with Interested Third Party or related Directors:
Personal shareholding in Interested Third Party or related entities (describe size and value of holding; direct or indirect ownership and control of the holding; date acquired; proportion of your portfolio etc):
Personal Trading in Interested Third Party or related entities' securities (last 12 months):
Firm's shareholding in Interested Third Party or related entities:
Note to Executive: Ensure all relevant third parties and their advisers are identified on a separate page for members' consideration.