Conflict‑of‑Interest Disclosure Form

(Complete and save as a pdf document. Submit to: mail@the-esg-institute.org)

A. Individual Details

  1. Full name: _______________________________________________

  2. Job title / role: ___________________________________________

  3. Department / business unit: _________________________________

  4. Country: _________________________________

  5. Email: ______________________________________________

  6. Date of completion (DD‑MM‑YYYY): __________________________

B. Interests to Declare

For each category below, indicate “Yes” or “No”. If “Yes”, provide full details in Section C. Include interests held by you or by a close family member or business partner if they could reasonably be perceived to influence your impartiality.

  1. External employment, consultancy or advisory positions: ____ Yes  /  No

  2. Significant shareholdings or ownership interests (>1 % or £10,000): ____ Yes  /  No

  3. Board memberships, trusteeships or officer roles in other organisations: ____ Yes  /  No

  4. Family or personal relationships with Company clients, suppliers or competitors: ____ Yes  /  No

  5. Personal or financial benefit from Company contracts, grants or research: ____ Yes  /  No

  6. Gifts, hospitality or sponsorships received in the last 12 months exceeding £50 in value: ____ Yes  /  No

  7. Any other situation that could create a real or perceived conflict of interest: ____ Yes  /  No

C. Details of Declared Interests (if any)

For each “Yes” above, reference the question number and provide: name of external entity, nature of interest or relationship, approximate value (if financial), start date and any steps already taken to mitigate the conflict.

(Attach additional pages if necessary.)

D. Declaration and Acknowledgement

I declare that the information provided in this form is complete, accurate and up to date to the best of my knowledge. I undertake to:

  • promptly notify the Company in writing if my circumstances change and a new or additional conflict arises; and

  • refrain from participating in any decision‑making or activity that could be influenced by a declared conflict until appropriate mitigations are agreed in writing.

I understand that failure to disclose a conflict of interest, or to comply with agreed mitigation measures, may constitute misconduct and result in disciplinary action.

Signature: ___________________________________ Date: ________________

E. For Office Use Only (Company Secretary / Compliance Officer)

Date received: _________________________
Review reference: ______________________
Action / mitigation required: ____________________________________________
Reviewer name & signature: ____________________________________________
Date: ___________________

This policy is to be reviewed every two years, or earlier if there are significant changes in law or our operations.

Latest update: June 30, 2025.

This Policy is non‑contractual and may be amended at the Company’s discretion.