‫ﻧﻤﻮذج اﻹﻓﺼﺎح ﻋﻦ ﺗﻀﺎرب اﳌﺼﺎلح‬

Conflict of Interest Declaration Form

The Purchasing Department at DGDA manages the ‫ﻳﺎت‬.-‫ﻴﺌﺔ ﺗﻄﻮيﺮ ﺑﻮاﺑﺔ اﻟﺪرﻋﻴﺔ ﺑﺈدارة ﻋﻤﻠﻴﺎت اﳌﺸ‬32 ‫ﻳﺎت‬.-‫ﺗﻘﻮم إدارة اﳌﺸ‬
procurement operations of the Authority. It is based
‫ اﻟﻔﺮص اﳌتﺴﺎويﺔ‬.M‫ى أﺳﺲ اﻟﻌﺪاﻟﺔ واﻟﺸﻔﺎﻓﻴﺔ وﺗﻮﻓ‬E‫ ﺗﻘﻮم ﻋ‬DC‫ﺑﺎﻟهﻴﺌﺔ واﻟ‬
on fairness and transparency and aiming to provide
equal opportunities for all who wishes to contract ‫ط‬.-‫ﻳﺎت تﺸ‬.-‫ ﻓﺈن إدارة اﳌﺸ‬،‫ى ذﻟﻚ‬E‫ ﺑﻨﺎء ﻋ‬.‫ن ﺑﺎﻟﺘﻌﺎﻗﺪ ﻣﻊ اﻟهﻴﺌﺔ‬M‫لجﻤﻴﻊ اﻟﺮاﻏﺒ‬
with DGDA. Accordingly, the Procurement
Department requires all participants in procurement ‫ﻣﻮا ﺑﺎﻹﻓﺼﺎح ﻋﻦ أﻳﺔ‬f-‫ﻳﺎت ﺑﺄن ﻳﻠ‬.-‫ن بﻌﻤﻠﻴﺎت واﺟﺮاءات اﳌﺸ‬M‫ﻛ‬.-‫ى كﺎﻓﺔ اﳌﺸ‬E‫ﻋ‬
operations to commit to disclosing any potential ‫ى ﻣﺴﺘﻮيﺎت الحﻔﺎظ‬E‫ى أﻋ‬E‫ى املحﺎﻓﻈﺔ ﻋ‬p‫ ﺑﺎﻹﺿﺎﻓﺔ إ‬،‫تﻌﺎرض ﻣﺼﺎلح ﻣﺤﺘﻤﻞ‬
conflict of interest, in addition to maintaining the
highest levels of confidentiality. Therefore, whoever ‫ كﻞ ﻣﻦ ﻳﻤﺘﻨﻊ ﻋﻦ ﺗﻮﻗﻴﻊ هﺬا اﻟﻨﻤﻮذج ﻓﺴﻮف ﻳﻤﻨﻊ‬،‫ ﻋﻠﻴﮫ‬.‫ى ﺳﺮيﺔ اﳌﻌﻠﻮﻣﺎت‬E‫ﻋ‬
refrains from signing this form will be prohibited
.‫ﻳﺎت ﺑﺎﻟهﻴﺌﺔ‬.-‫ي أﻳﺔ ﺟﺰء ﻣﻦ ﻋﻤﻠﻴﺎت واﺟﺮاءات اﳌﺸ‬z ‫ﻣﻦ اﳌﺸﺎرﻛﺔ‬
from participating in any part of the DGDAs
procurement operations.

A potential conflict of interest is considered to be any ‫ى ﺳبﻴﻞ اﳌﺜﺎل‬E‫ ﺗﺮد ﻋ‬DC‫يﻌﺪ تﻌﺎرض ﻣﺼﺎلح ﻣﺤﺘﻤﻞ أّي ﻣﻦ الحﺎﻻت اﻟﺘﺎﻟﻴﺔ –واﻟ‬
of the following cases, which are, but are not limited :-‫ﻻ الحﺼﺮ‬
to:
1. Kinship up to the fourth degree between one of ‫ن أﺣﺪ ﻣﻼك اﻟﺸﺮﻛﺔ ﻣﻊ أﺣﺪ ﻣنﺴﻮبﻲ‬M‫… اﻟﺪرﺟﺔ اﻟﺮابﻌﺔ ﺑ‬C‫اﻟﻘﺮاﺑﺔ ﺣ‬ .1
the owners of the company with one of the .‫اﻟهﻴﺌﺔ‬
employees of DGDA.
2. The existence of a direct relationship or partial ‫ي‬z ‫وﺟﻮد ﻋﻼﻗﺔ ﻣﺒﺎﺷﺮة أو ﻣﺸﺎرﻛﺔ ﺑﺎﳌﻠﻜﻴﺔ ﻣﻦ ﻗﺒﻞ أﺣﺪ ﻣنﺴﻮبﻲ اﻟهﻴﺌﺔ‬ .2
ownership by one of the DGDA's employees in .‫اﻟﺸﺮﻛﺔ‬
the company.

If there is any possibility of a potential conflict of ‫ ﻓﻴﺠﺐ ﻋﻠﻴﻜﻢ‬،‫ي ﺣﺎل وﺟﻮد أﻳﺔ اﺣﺘﻤﺎل بﺸﺄن وﺟﻮد تﻌﺎرض ﻣﺼﺎلح ﻣﺤﺘﻤﻞ‬z
interest, you must disclose it below. .‫اﻹﻓﺼﺎح ﻋﻦ ذﻟﻚ أدﻧﺎﻩ‬

o I would like to disclose a conflict of interest (s): :‫ﺣﺎﻻت تﻌﺎرض ﻣﺼﺎلح‬/‫ أرﻏﺐ ﺑﺎﻹﻓﺼﺎح ﻋﻦ ﺣﺎﻟﺔ‬o
1. 1
2. 2
3. 3
o I have no conflicts of interest. .‫ ﻻ ﻳﻮﺟﺪ ﻟﺪي أﻳﺔ ﺣﺎﻻت تﻌﺎرض ﻣﺼﺎلح‬o

Company Stamp Authorized Signature

‫ﺧﺘﻢ اﻟﺸﺮﻛﺔ‬ ‫ﺗﻮﻗﻴﻊ ﻣﻌﺘﻤﺪ‬