DECLARATION OF INTEREST FORM

Name ................................................. Position .................................................

Have you, or anyone in your family, any financial or other interest in any pharmaceutical manufacturer or supplier, and which may constitute a real, potential or apparent conflict of interest?

Please tick: Yes No

Have you had, during the past 4 years, any employment or other professional relationship with any organization that is a pharmaceutical manufacturer or supplier or represents such organizations?

Please tick: Yes No

If you answered ‘yes’ to either question, please give details in the box below.

Type of interest, for example patents, shares, employment, association, payment*

Name of commercial entity

Belongs to you, your family or work unit?

Current interest? or year that interest ceased

* Amounts do not have to be declared

Is there anything else that could affect, or be perceived to affect, your objectivity or independence in carrying out your duties in the DTC?

__________________________________________________________
__________________________________________________________

I hereby declare that the disclosed information is correct and that no other situation of real, potential, or apparent conflict of interest is known to me. I undertake to inform you of any change in these circumstances.

Signature ................................................. Date ............................................