LAC's Conflict of Interest Form

LAC's Conflict of Interest Form

If you believe you have a Conflict of Interest to declare then please submit it to the ATC Co-Ordinator using this online form
ATC Information

This has already been supplied
ATC Name
ATC Number
ATC Co-ordinator
ATC Co-ordinator Email
Your personal Information:
Name*

First NameLast Name
STA Reference Number*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Role(s) carried out for LAC Training's ATC: (select all that apply)*

AdministrationTutorAssessorIQA
Conflict of Interest Details:
Please indicate below the intent of this form.*

I have no conflict of interest to reportI have a conflict of interest to report, the details of which are included within this disclosure
Your declaration of a conflict of interest must include the following information:

• The type of interest
• The nature of the interest
• A description of all personnel involved in the interest, financial or non - financial, and/or any other relevant information (for example, the name of the learner)

Please describe below any relationships, transactions, positions you hold (volunteer or otherwise), or circumstances that you believe could contribute to a conflict of interest between the Safety Training Awards approved training centre and your personal interests – financial or otherwise.

Please refer to the Safety Training Awards conflict of interest policy for more information.
Declaration of conflict of interest
I acknowledge that the above conflict of interest exists and, to the best of my knowledge, I have informed LAC Training / Safety Training Awards of this, including all relevant information relating to the conflict of interest.
Signature*

Clear
Date*

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Date
Should be Empty:

LAC's Conflict of Interest Form

ATC Information

Your personal Information:

Conflict of Interest Details: