CONFLICT OF INTEREST / HOSPITALITY DECLARATION FORM 
 
 
 
I, ..................................................................................................................................................................... 
(Name) 
 
confirm I have received the following hospitality/declare the following conflict of interest 
 
from/with ...................................................................................................................................................... 
(Name of entity providing hospitality/with whom there is a conflict of interest) 
 
......................................................................................................................................................................... 
(Describe, hospitality/conflict of interest) 
 
 
valued at $..................................................................................................................................................... 
 
 
 
 
(Signed)  
(Date) 
 
 
 
If total value of hospitality (over a 12 month period) is valued at over $100.00 have 
your line manager complete. 
 
Prior approval was given for the above hospitality. 
 
 
 
 
(Name)  
 
 
 
 
(Signed)  
(Date) 
 
 
 
 
Please send completed form to:  
Disclosure Register 
Corporate Office 
2nd Flr, H Block 
TPMH 

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