The conflict of interest annual disclosure is to be completed by all Selwyn District Council employees who have a financial delegation by 30 June each year.

Note - the information obtained through completion of this questionnaire will remain confidential and access will be restricted.

Read the Conflict of Interest Policy and Delegations Manual by requesting copies from the Corporate Accountant.

Your Name:
Financial Interests
1. Do you have or do you know if an immediate family member has a financial interest in an entity we do business with or controls any shares or debt or equity securities, or have any other investment interest in an entity we do business with? You may exclude ownership or control of shares in publicly listed companies, unless it is likely that you will be involved in the management of our business relationship with that entity or you are likely to be involved in making business contract decisions in relation to that entity.
Yes (describe below) No
Business Interests
2. Do you have or do you know if an immediate family member has any private business dealings with an entity we do business with that generate revenue or expenses for you (excluding normal business as a member of the public)? If yes, you should disclose the nature of the dealings and the revenue or expenses generated.
Yes (describe below) No
3. Do you have or do you know if an immediate family member has any legal or serious dispute involving an entity we do business with or with Selwyn District Council?
Yes (describe below) No
4. Do you have or do you know if an immediate family member has any governance, management or membership role, or other professional business association with any: trusts, societies, community, advocacy or similar groups that receive financial grants or support from Selwyn District Council?
Yes (describe below) No
5. Do you have or do you know if an immediate family member has any private business association, contracts, or dealings with a Selwyn District Councillor, Community Board Member or Senior Manager?
Yes (describe below) No
Personal Relationships
6. Do you have any close personal relationships with an owner, director, or senior manager of an entity we do business with?
Yes (describe below) No
7. Do you have any close personal relationships with a Selwyn District Councillor, Community Board Member or member of senior management that could create an actual or perceived conflict of interest?
Yes (describe below) No
Employment Relationships
8. Do you know if any of your family members recently accepted (or are intending to accept) a senior management position with an entity we do business with?
Yes (describe below) No
9. Do you know if any of your family members are a member of the governing body of an entity we do business with?
Yes (describe below) No
10. Do you know if your spouse (or partner) is a member of a news media organisation, or someone who writes or prepares articles, or broadcasts for public media?
Yes (describe below) No
Declarations
I am aware of the need to notify my manager of any future material changes to disclosed circumstances, or any new material circumstances requiring disclosure.
I have truthfully answered all questions in this declaration and have disclosed to my manager all relevant facts known to me that could create a real or potential threat to my independence as an employee of Selwyn District Council, or a real or potential conflict of interest.
I acknowledge that I have read and understood Selwyn District Council's Conflict of Interest Policy, including all appendices. I agree to comply with all aspects of this policy and understand that failure to adhere to this policy may result in disciplinary action. I am aware that I am able to seek further information and guidance from my manager or the Corporate Accountant.
Submit