Your COMPANY LIMITED REGISTER OF INTEREST

Register of Interests Declared as at: Name: Title: 1. Company Interest Any relationship with a named company with
which XXXX Group might do business including ownership or partownership, major shareholdings or other beneficial interests such as warrants and options; Directorship, paid employment, consultancy and close family connection. Company Employment Type

2. Self-Employment - names of any client accounting for more than

5% of your total annual earned income

3. Property - Freehold or leasehold ownership of any properties in

which XXXX might have an interest.

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4. Charities Trusteeships or employment with any charities or

voluntary organizations. Organization Charity Details

5. Public Appointments Remuneration or unremunerated.

Organization Appointment Details

bodies, trade or other associations. Organization Membership Details

6. Memberships Including membership of professional or external

7. Close Family Links Specific close family interest in any of the

above. The definition of close is up to the registrant to decide. It is appreciated that a declaration may be difficult to declare if information is not forthcoming from a family member.

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8. Other Interests - Any other interests not covered by the above

categories.

I confirm that the above declaration is complete and correct to the best of my knowledge and belief.

Signature:

Date:

Note: XXXXCompany Limited will not use information provided on this form for any other purpose than the Register. Any form obtained electronically must be signed and returned in hard copy.

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