CONFLICTS OF INTEREST DISCLOSURE FORM
Date
Panelist Name: _________________________________
Position/Role: _________________________________
I, _________________________________, acknowledge that I have been selected as a
panelist for the interview process at Bridging Gap Solutions. In order to ensure transparency
and maintain the integrity of the selection process, I hereby disclose any potential conflicts of
interest that may arise during my participation.
Please provide the following information:
Are you related to any of the candidates being interviewed?
[ ] Yes
[ ] No
If yes, please specify the relationship: _________________________________
Have you worked with any of the candidates being interviewed in a professional capacity?
[ ] Yes
[ ] No
If yes, please provide details of the professional relationship:
_________________________________
Do you have any financial interests, including ownership or stock options, in any company
that the candidates represent or are affiliated with?
[ ] Yes
Plot No 29954, Corner of Manchinchi & Paseli Road, Northmead, Lusaka, Zambia.
www.bgsgroup.co.zm
Tel: +260 211 255 910 Cell: +260 955 486 754
Enquiries@bgsgroup.co.zm
[ ] No
If yes, please provide details of the financial interest:
_________________________________
Are you currently involved in any ongoing personal, business, or financial relationships that
could potentially influence your judgment during the interview process?
[ ] Yes
[ ] No
If yes, please provide details of the relationship: _________________________________
Is there any other information that you believe may present a conflict of interest or
compromise your impartiality as a panelist for this interview process?
[ ] Yes
[ ] No
If yes, please provide details: _________________________________
I hereby declare that the information provided above is true and accurate to the best of my
knowledge. I understand that any conflicts of interest disclosed will be taken into
consideration by Bridging Gap Solutions Limited and may result in appropriate actions,
including but not limited to recusal from the interview panel.
Full Name:…………………………………………………………….
Signature:……………………………………………………………..
Date:………………………………………………………………….
Note: This form should be completed and returned to the HR before the commencement of
the interview process.
Plot No 29954, Corner of Manchinchi & Paseli Road, Northmead, Lusaka, Zambia.
www.bgsgroup.co.zm
Tel: +260 211 255 910 Cell: +260 955 486 754
Enquiries@bgsgroup.co.zm
