Lusaka Head Office:

Copperbelt Regional Office: Unit No 6, Palm Villas,

Solwezi, Mukwa Road
Copperbelt, Eureka Park,
Zambia Lilayi,
Lusaka,
+260 77 964 9440 Zambia
service@zamaka.org +260 96 446 7257

VAT Reg No: 1008325808 Reg No: 120180001689 info@zamaka.org

CONFLICT OF INTEREST DECLARATION FORM

Employee Details:
Full Name : _________________________________________

Employee ID / NRC No : _________________________________________

Company No : _________________________________________

Department / Site : _________________________________________

Position / Designation : _________________________________________

DECLARATION

1. External Business Interests:

Are you currently involved in any business activities outside of your employment with the Company?
(This includes ownership, directorship, partnership, or any significant financial interest in another
company.)
[ ] Yes
[ ] No
If yes, please provide details:

Full Name of the Business : ______________________________________________________

Nature of Business : ______________________________________________________

Your Role / Position : ______________________________________________________

Extent of Involvement : ______________________________________________________

2. Potential Conflicts of Interest:

Do any of your external business activities or personal interests potentially conflict with your duties
and responsibilities at the Company?
[ ] Yes
[ ] No
If yes, please provide details:

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3. Use of Company Resources:
Have you ever used, or do you intend to use, any Company property, information, or your position
within the Company for personal gain or to benefit any external business activities?
[ ] Yes
[ ] No
If yes, please provide details:

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4. Additional Information:
Is there any other information you believe is relevant to your declaration of interests that could be
seen as a conflict with the Company’s interests?
[ ] Yes
[ ] No
If yes, please provide details:

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Employee Confirmation

I hereby declare that all the information provided in this form is true and complete to the best of my knowledge.
I understand that failure to disclose any potential conflicts of interest or engaging in activities that conflict with the
Company’s interests may result in disciplinary action, including possible termination of employment.
I agree to promptly inform my supervisor or the HR department if there are any changes to my external business
activities or other interests that may present a conflict of interest in the future.

Employee Signature: _______________________________ Date: ____________________________

Supervisor Review

Reviewed by (Full Name) : ______________________________________________________

Position / Designation : ______________________________________________________
Signature : ______________________________________________________
Date : ______________________________________________________

Please complete this form and return it to the HR department by Close of Business on the 7th of June 2024.
If you have any questions or need further clarification, please contact your supervisor or the HR department.

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