Sub Grantee Conflict Of Interest Declaration Form

Name (of person making the Declaration):(Required)

First Last

Position / title:(Required)

Organization:(Required)

Country(Required)

Select country below

Declaration(Required)

I understand my role as a staff of Sub-grantee under Amref managed Program and I make this declaration in good faith.

Conflict of Interest

Select one of the following two options:(Required)

Select the type of conflict of interest:(Required)

Describe the circumstances giving rise to the conflict of interest(Required)

(Please include the name of the entity or person, the nature and extent of the interest or relationship, timeline, organization's resources/facilities, and any other information necessary to an understanding of the Conflict of Interest)

Conflict of interest management plan:( select one or all that apply)(Required)

Exclude yourself from evaluation of performance appraisals

Exclude yourself from evaluation or approval of staff contracts.

Exclude yourself from approval of transactions relating to vendors

Resignation from the position that causes the conflict of interest.

Relinquish the business interest that causes the conflict of interest

Any other management plan(s) (provide further details in section below)

Consent of the person making the Declaration

Name(Required)

First Last

Title(Required)

Signature(Required)

Sign online using a mouse or stylus.

Date

Principal recipient representative approving the management plan (Amref Staff )

Name(Required)

First Last

Email(Required)

Date