Declarations of Interest Register
I _________________________________ as Independent Strategic Advisory Board (ISAB) member / employee / volunteer of Healthwatch Kingston Upon Hull have set out below my interests in accordance with the organisation’s conflicts of interest policy.
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Category |
Please give details of the interest and whether it applies to yourself or, where appropriate, a member of your immediate family, connected persons or some other close personal connection. | |
| Current employment and any previous employment in which you continue to have a financial interest. | ||
| Appointments (voluntary or otherwise) eg. trusteeships, directorships, local authority membership, tribunals etc. | ||
| Membership of any political or professional bodies, special interest groups or mutual support organisations. | ||
| Investments in unlisted companies, partnerships and other forms of business, shareholdings and beneficial interests. | ||
| Gifts or hospitality offered to you by external bodies and whether this was declined or accepted in the last twelve months. | ||
| Any contractual relationship with Healthwatch Kingston Upon Hull or Meeting New Horizons CIC. | ||
| Any other conflicts that are not covered by the above. |
Declaration
To the best of my knowledge, the above information is complete and correct. I undertake to update as necessary the information provided, and to review the accuracy of the information on an annual basis. I give my consent for it to be used for the purposes described in the conflicts of interest policy and for no other purpose.
Signed: _____________________________________________________________
Print Name: _________________________________________________________
Position: ____________________________________________________________
Date: _____________________