Attachment 6 STRICTLY CONFIDENTIAL REGISTRATION OF

Attachment 6
STRICTLY CONFIDENTIAL
REGISTRATION OF PERSONAL INTERESTS FORM
To <insert name of GOC or other statutory body>
Particulars of my personal pecuniary and other relevant interests and those of my immediate
family of which I am aware are set out in the attached form.
I undertake to advise you should a situation arise where an interest of mine or an interest of a
member of my immediate family of which I am aware, whether that interest is pecuniary or
otherwise, conflicts, or may reasonably be thought to conflict, with my public duty.
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name (block letters)
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(signature)
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(position)
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(date)
STRICTLY CONFIDENTIAL
Return of Personal Interests of Officer and Immediate Family (including spouse and dependent children)
Real Estate
Real Estate in which a beneficial interest is held other than principal place of residence:
Location
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Owner
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Purpose for which held
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Share Holdings (where total value exceeds $5,000)
Include registered shares, options and current applications (other than nominal share holdings
by way of qualification for membership of a credit union, building society or other cooperative society):
Owner of shares
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Name of Company
(including holding companies and subsidiary companies if
applicable)
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Directorships in Companies
In regard to any directorships, whether remunerated or not:
Name of Director
Name of Company
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Activities of Company
whether public or private
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Nature of Operations
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Nature of Business Interest
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Partnerships etc.
Person holding interest
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STRICTLY CONFIDENTIAL
Investments
Investments in bonds, debentures, savings or investment accounts with banks or other
financial institutions (exceeding a cumulative value of $5,000).
Person holding Investment
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Type of Investment
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Body in which Investment is held
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Other Assets
List each asset valued at over $5,000 including collections. Household or personal effects
and motor vehicles for personal use are to be excluded:
Owner of Asset
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Nature of Asset
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Employment by a public or private company
Exclude salary from principal public sector employment:
Person receiving income
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Nature and annualised amount of income
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Any Gifts, Substantial Sponsored Travel or Hospitality exceeding $100
Person receiving Gift etc
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Nature of Gift etc
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STRICTLY CONFIDENTIAL
Liabilities
Liabilities exceeding $5,000 other than mortgage over principal place of residence
Person concerned
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Nature of liability
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Creditor
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Other Interests - including membership or office holding of an organisation other than
an industrial or professional organisation, or a political party
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