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    Attachment 4 - Registration of Personal Interests Form (Example)1

    To <insert name of Government 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.

    name (block letters)




    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:





    Purpose for which held


    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 co-operative society):

    Owner of shares


    Name of Company (including holding companies and subsidiary companies if applicable)


    Directorships in Companies

    In regard to any directorships, whether remunerated or not:

    Name of Director


    Name of Company


    Activities of Company whether public or private


    Partnerships etc.

    Person holding interest


    Nature of Operations


    Nature of Business Interest



    Investments in bonds, debentures, savings or investment accounts with banks or other financial institutions (exceeding a cumulative value of $5,000).

    Person holding Investment


    Type of Investment


    Body in which Investment is held


    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


    Nature of Asset


    Employment by a public or private company

    Exclude salary from principal public sector employment:

    Person receiving income


    Nature and annualised amount of income


    Any Gifts, Substantial Sponsored Travel or Hospitality exceeding $100

    Person receiving Gift etc


    Nature of Gift etc



    Liabilities exceeding $5,000 other than mortgage over principal place of residence

    Person concerned


    Nature of liability




    Other Interests - including membership or office holding of an organisation other than an industrial or professional organisation, or a political party


    1. Sourced from Department of the Premier and Cabinet Code of Conduct, November 2009.

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    Last updated:
    18 May, 2016
    Last reviewed:
    29 July, 2010