CONFLICT OF INTEREST DECLARATION FORM Conflict of Interest Policy applies to ECTS Board Members, Committee Members and senior staff 1 Personal informationName* First Last Email* Please specify your role in ECTS* Board of Directors Committee/Action Group Member Staff/Consultant 2 DeclarationPlease give details of the interest and whether it applies to yourself, or where appropriate, a member of your immediate family or some other close personal connectionCurrent employment and any previous employment in which you continue to have a financial interest*Disclosure on the Conflict of Interest registry available on the ECTS Members’ only website* Yes No Appointments (voluntary or otherwise) eg: trusteeships, directorships, local authority membership, tribunals etc, additional self-employed contracts*Disclosure on the Conflict of Interest registry available on the ECTS Members’ only website* Yes No Membership of any professional bodies, special interest groups or mutual support organisations*Disclosure on the Conflict of Interest registry available on the ECTS Members’ only website* Yes No Investments in unlisted companies, partnerships and other forms of business, major shareholdings and beneficial interests*Disclosure on the Conflict of Interest registry available on the ECTS Members’ only website* Yes No Research grants, consultancy fees and honorarium*Disclosure on the Conflict of Interest registry available on the ECTS Members’ only website* Yes No Gifts or hospitality offered to you by external bodies and whether this was declined or accepted in the last twelve months*Disclosure on the Conflict of Interest registry available on the ECTS Members’ only website* Yes No Do you use, or care for a user, of the organisation’s services?*Disclosure on the Conflict of Interest registry available on the ECTS Members’ only website* Yes No Any contractual relationship with ECTS*Disclosure on the Conflict of Interest registry available on the ECTS Members’ only website* Yes No Any other conflicts that are not covered by the above*Disclosure on the Conflict of Interest registry available on the ECTS Members’ only website* Yes No StatementDate MM slash DD slash YYYY The undersigned hereby:* Declare that the above information is complete and correct Acknowledge the above noted actual or potential conflic of interest and agree to mitigate this in accordance with the organisation’s conflict of interest policy Agree to update as necessary the information provided, and to review the accuracy of the information on an annual basis Give my consent for it to be used for the purposes described in the conflicts of interest policy and for no other purpose CAPTCHA