Conflict of Interest

Private and Confidential

Relationship to others

Is there any relationship, either internal or external, which you feel could cause potential or apparent
conflict of interest with your Active Prospects activities?

Yes ☐ No ☐
If yes, please provide further details of the relationship below:
Click or tap here to enter text.

Please answer the following:

Do you have a relationship with any other person employed with Active Prospects, Board Choose
Member, contractor, or Person We Support? an item.

If yes, please detail to us who you have a relationship with and the nature of this relationship:
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Have you engaged in any other paid work in the last calendar year other than that which has Choose
been pre-approved? an item.

If yes, please detail to us the other work or activities, listing the organisation(s) you have worked for, the
duties performed, and the time spent on the work:
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Do you have outside activities (i.e. those whilst not in the employment of Active Prospects) Choose
that involve People We Support? an item.

If yes, please detail to us the other work or activities where you come into contact with the people we
support:
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To your knowledge, do you or any member of your immediate family have a significant or Choose
influential relationship with any of the following: an item.
 A third party, whose actions you can influence, who does business with Active
Prospects
 Any other business in which there could be a conflict of interest

If yes, please give details of the relationship or financial interest. Example: ‘Son, MD of Company X,
contractor providing maintenance to Active Prospect Services’
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Please turn over

2021.02
 Do you hold any position or appointment as a Director (Executive or Non-executive) or Choose
Company Secretary in any company, whether or not this company does business with an item.
Active Prospects?

If yes, please detail the positions: give date of appointment, name & address of company and state how
the company is involved IN ANY WAY with Active Prospects
Click or tap here to enter text.

Are you aware of any other circumstances that could constitute a conflict of interest with Choose
your position within Active Prospects? an item.

If yes, pleas give details of any other conflict of interest with your position within Active Prospects that
you are aware of
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I confirm that the above information is true and correct and has been completed to the best of my
knowledge.

Printed Name: Sign:

Click or tap here to enter text. Click or tap here to enter text.
Date:
Click or tap to enter a date.

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V3 – 2021.02