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Conflicts of Interest Declaration Form For Suppliers

This document contains a conflicts of interest declaration form for suppliers and contractors doing business with AngloGold Ashanti. It states that suppliers must declare any potential conflicts at the start of the tender process or as they arise. Failing to disclose conflicts could prohibit the supplier from conducting business with AngloGold Ashanti and existing contracts may be terminated. The declaration form asks suppliers to disclose any relationships between their company and current or former AngloGold Ashanti employees, government officials, or if they have a current working relationship with an AngloGold Ashanti employee from the past 2 years.

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Amine Diaby
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2K views2 pages

Conflicts of Interest Declaration Form For Suppliers

This document contains a conflicts of interest declaration form for suppliers and contractors doing business with AngloGold Ashanti. It states that suppliers must declare any potential conflicts at the start of the tender process or as they arise. Failing to disclose conflicts could prohibit the supplier from conducting business with AngloGold Ashanti and existing contracts may be terminated. The declaration form asks suppliers to disclose any relationships between their company and current or former AngloGold Ashanti employees, government officials, or if they have a current working relationship with an AngloGold Ashanti employee from the past 2 years.

Uploaded by

Amine Diaby
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Group Legal, Ethics and Compliance

Declaration of Conflicts of Interest for Suppliers

All potential suppliers / contractors must complete a conflicts of interest declaration at the beginning of
the tender process for appropriate review. In addition, suppliers / contractors must immediately declare
a conflict of interest when it arises or is perceived to arise.

Failing to make the required declarations may prohibit you from conducting business with AngloGold
Ashanti and any existing contracts may be terminated for cause.

Supplier Name (Company): ___________________________________________________________

Address: _________________________________________________________________________

Contact Person: ____________________________________________________________________

Contact Details: ____________________________________________________________________

Company Registration number: ________________________________________________________

1. Does any current or former AngloGold Ashanti employee have a financial interest or key role in the
company (senior management, etc.)?

Yes No

If yes, please provide the name of the former AngloGold Ashanti employee/s, his/her previous role/s
at AngloGold Ashanti, and his/her current relationship to your company below:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

2. Is any owner, director or key employee at your company a government official1 or have a close
relationship with a government official?

Yes No

1 A Government Official means:


• Any officer, employee or representative of a government, whether national, federal, provincial,
regional or local;
• Any person exercising, administrative, judicial or legislative functions, whether appointed or
elected;
• An officer of an entity owned or controlled by a government and any business venture that is
owned or controlled by government;
• Any candidate for or holder of public office;
• Any official of a political party;
• Any official or representative of an public international organization; or
• Any member of a royal family (acting on behalf of that family).

DOCUMENT IDENTIFICATION: May 2018


If yes, please details of the nature of information used.

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

3. Does any owner, director or key employee at your company have a current working relationship or
have they worked in the past 2 years with an employee at AngloGold Ashanti?

Yes No

If yes, please provide the names of the relevant owner/director/key employee and the AngloGold
Ashanti employee below and describe the relationship in more detail:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

4. Please provide any other information you consider relevant to disclose under the Policy on Conflicts
of Interest.

If in doubt please disclose:

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Declaration

I, the undersigned declare the above information to be true and correct.

______________________________________________________________________
Senior Company Representative (including title):

Date: _________________________________________________________________

DOCUMENT IDENTIFICATION: May 2018

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