Conflict of Interest DECLARATION

Explanation and Instructions

Appointment to Public Agencies, Boards and Commissions

All members of a public agency, board or commission (ABC) must act impartially in carrying out their responsibilities. As a candidate under consideration for appointment to a public ABC, you are required to identify and disclose any real or apparent conflicts of interest. In the event you are appointed, you have a continuing obligation to disclose, in writing, any real or apparent conflicts of interest in accordance with the public ABC’s disclosure practice.

This document sets out information to assist you in identifying real or apparent conflicts of interest. Please (1) read this document, and (2) complete and sign the attached Conflict of Interest Declaration.

What is a real or apparent conflict of interest?

This includes any interest that actually conflicts, may conflict, or may reasonably appear to conflict with a candidate’s responsibilities as a member of a public ABC. The existence of a real or apparent conflict of interest will not necessarily preclude a candidate from serving on a public ABC.

When does a real or apparent conflict of interest exist?

You have a private interest that influences or appears to influence the objective exercise of your responsibilities as a member;

Your private interests are at variance to or in conflict with your duties and/or responsibilities as a member; or

You gain or appear to gain advantage, for yourself or others, by virtue of your role as a member.

What do private interests include?

Private interests include a personal obligation, financial interest, business interest or an interest of a closely associated person. Private interests may also include involvement in an appointment, business, undertaking or employment.

Business interests: include any interest arising as a result of your current, former or prospective affiliation with any for profit, not-for-profit or charitable entity.

Affiliation: includes being a member, employee, volunteer, owner, shareholder, creditor, director, elected representative, appointee, or trustee of an entity, or having any legal or equitable interest in such an entity.

Entity: includes a corporation, partnership, sole proprietorship, firm, franchise, association, trust, organization, holding company, joint venture, society, or institution.

Closely associated person: includes persons with whom you have a substantial relationship such as a spouse, adult interdependent partner, child, other relative, close friend, employer, business associate, or client.

What do private interests not include?

An interest in a matter that is of general application.

An interest in a matter that affects you as part of a broad class of the public. This means, for example, that a decision of the public ABC would affect you in the same way as it would affect others in the broad class.

An interest that is trivial. This means that the interest may be a private interest, but it is of such minor significance that it is trivial.

CONFLICT OF INTEREST DECLARATION

LAPP Board of Directors

(A separate form must be completed for each ABC that the Candidate is being considered)

Name of Candidate:

Opportunity/Role:

Candidate Declaration

☐I have no real or apparent conflicts of interest to declare at this time.

☐I have interests to declare that may actually conflict, or appear to conflict, with my responsibilities as a member of the public ABC.

Please list the interests declared below. If you are not sure if you have a real or apparent conflict of interest, please explain. Attach additional sheets if you need more space:

I, , declare that the information provided on this form is a complete and accurate accounting of any actual or apparent conflict(s) of interest that may affect my responsibilities as a member of the public ABC of which I am aware at this time.

I understand that I have a continuing obligation following my confirmed appointment, to disclose in writing, any actual or apparent conflicts of interest that arise prior to, and during, any term of appointment in accordance with the public ABC’s disclosure practice.

I understand that, if appointed, the public ABC may conduct an additional assessment of real or apparent conflict of interest based on their Code of Conduct and/or internal process. This form does not serve as a final determination regarding whether any interest actually conflicts, may conflict, or may reasonably appear to conflict with my responsibilities as a member of the public ABC. I understand that if I am determined to have a real or apparent conflict of interest by the public ABC, it is up to the public ABC to determine steps for managing that conflict of interest.

Candidate’s Signature:

Date:

The personal information on this form is collected pursuant to section 33(c) of the Freedom of Information and Protection of Privacy Act, for the purpose of assessing the suitability of candidates for an appointment to the public ABC. If you have any questions, please contact [Title], Executive Search, Alberta Public Service Commission: 780-408-8460; psc.executivesearchservices@gov.ab.ca; Peace Hills Trust 10011 - 109 Street, Edmonton, Alberta T5J 3S8.

For Program Area’s Use: Follow up required: Y/N Date Completed (dd/mm/yy): Comments: