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Conflict of Interest Disclosure Form

This conflict of interest disclosure form contains three sections for employees to disclose any potential conflicts with their (1) family and romantic relationships, (2) financial interests, and (3) outside business activities that may interfere with their duties at Delivery Hero. Employees are asked to describe any relevant situations and relationships that could pose an actual or perceived conflict of interest according to Delivery Hero's policy. By signing, employees certify that their responses are complete and honest. The purpose is to help employees identify conflicts and enable the compliance department to provide advice on appropriate measures.

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Mauricio Galvis Turrini
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© © All Rights Reserved
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67 views

Conflict of Interest Disclosure Form

This conflict of interest disclosure form contains three sections for employees to disclose any potential conflicts with their (1) family and romantic relationships, (2) financial interests, and (3) outside business activities that may interfere with their duties at Delivery Hero. Employees are asked to describe any relevant situations and relationships that could pose an actual or perceived conflict of interest according to Delivery Hero's policy. By signing, employees certify that their responses are complete and honest. The purpose is to help employees identify conflicts and enable the compliance department to provide advice on appropriate measures.

Uploaded by

Mauricio Galvis Turrini
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Conflict of Interest Disclosure Form

First and Last Name:

Title:

This form was designed to detect and disclose a potential conflict of interest as per the Delivery Hero
Conflict of Interest Policy.

The purpose of the Conflict of Interest Policy is to help employees identify and deal with situations that may
give rise to potential or actual Conflicts of Interest. Every employee of Delivery Hero must act in Delivery
Hero’s best interests and exercise sound judgment, free from personal interests. A Conflict of Interest exists
when an Employee’s private interest (or the interest of his/ her Relative or Person of Romantic Interest)
interferes or appears to interfere, with the interests of the Company as a whole.

This disclosure form has 3 sections:


Section 1: Family and Romantic Relationships
Section 2: Financial Interests
Section 3: Outside Business Activities

How to fill out the form:

 Mark with an X the option(s) that best describes the potential Conflict of Interest that you would like
to disclose and provide much information as possible. 

 If you have no conflict to report then mark that option with an X for each section.

 If a potential conflict is disclosed, the Compliance Department will assess the disclosure and advise
on mitigation measures if deemed required.

 If you have any questions while filling out this form, please contact the Central Compliance
Department ([email protected]).

Remember the following definitions: 

Relative:
Your spouse, partner, parents, siblings or all other family members by blood or by law. 

Person of Romantic Interest:


Any person with whom an Employee has a romantic relationship outside of his/her work for Delivery
Hero, including co-Employees, customers and business partners with whom the Employee may have
developed such relationship in the course of employment with Delivery Hero. 

Financial Interest:
Refers to:
1. the ownership of 3% or more of the outstanding stock or other securities of a public or private
company or other entity; or
2. the right to receive compensation or payment or other benefits from an entity in any form
(including, but not limited to, bonus, salary, commission, etc.). 

Page 1 of 5
Section 1: Family and Romantic Relationships 

☐ I work in the same department as my Relative or Person of Romantic Interest. 

Specify the nature of the relationship, how long this has been happening, any measures you have taken to
avoid this, have you discussed this with anyone else, etc. 

☐ I am the direct/indirect manager of my Relative or Person of Romantic Interest. 

Specify the nature of the relationship, how long this has been happening, any measures you have taken to
avoid this, have you discussed this with anyone else, etc. 

☐ My Relative or Person of Romantic Interest is my direct/indirect manager. 

Specify the nature of the relationship, how long this has been happening, any measures you have taken to
avoid this, have you discussed this with anyone else, etc. 

☐ My Relative or Person of Romantic Interest and I belong to the same management team. 

Specify the nature of the relationship, how long this has been happening, any measures you have taken to
avoid this, have you discussed this with anyone else, etc. 

☐ Other. 

Please explain.

☐ I have no conflict of interest to report.

Page 2 of 5
Section 2: Financial Interests

☐ I have a direct/indirect Financial Interest in a current or potential competitor, customer, partner,


vendor or supplier of Delivery Hero. 

Specify details of financial investment (where, what, for how long), how did you find out about the potential
conflict, any measures you have taken to avoid this, have you discussed this with anyone else, etc. 

☐ My Relative or Person of Romantic Interest has a direct/indirect Financial Interest in a current or


potential competitor, customer, partner, vendor, supplier of Delivery Hero. 

Specify details of financial investment (who, where, what, for how long), how did you find out about the
potential conflict, any measures you have taken to avoid this, have you discussed this with anyone else, etc. 

☐ I work for a competitor, customer, partner, vendor or supplier of Delivery Hero. 

Specify details of relationship (where, what, for how long), how did you find out about the potential conflict,
any measures you have taken to avoid this, have you discussed this with anyone else, etc. 

☐ My Relative or Person of Romantic Interest works for a competitor, customer, partner, vendor,
supplier of Delivery Hero. 

Specify details of relationship (where, what, for how long), how did you find out about the potential conflict,
any measures you have taken to avoid this, have you discussed this with anyone else, etc. 

☐ Other. 

Please explain. 

☐ I have no conflict of interest to report.

Section 3: Outside Business Activities 

☐ I would like to serve as a board member or technical advisor of a Delivery Hero competitor or of a
company that may reasonably be expected to become a competitor. 

Specify details of role (where, what, when, for how long), nature of the company, any measures you have
taken to avoid this, have you discussed this with anyone else, etc. 

Page 3 of 5
☐ I would like to serve as a board member or technical advisor of a non-competing business. 

Specify details of role (where, what, when, for how long), nature of the company, any measures you have
taken to avoid this, have you discussed this with anyone else, etc. 

☐ I would like to accept a board position or technical advisor position (paid or unpaid) with a current
or potential customer, partner, vendor or supplier of Delivery Hero. 

Specify details of role (where, what, when, for how long), nature of the company, any measures you have
taken to avoid this, have you discussed this with anyone else, etc. 

☐ I would like to serve as a public official in a government entity (i.e. any national, state, provincial,
regional or local government, agency or other public body). 

Specify details on role (where, what, when, for how long), nature of the public body, any measures you have
taken to avoid this, have you discussed this with anyone else, etc. 

☐ Other. 

Please explain. 

☐ I have no conflict of interest to report.

Page 4 of 5
I hereby certify that the information set forth above is true and complete to the best of my knowledge.

First and Last Name

Title

Signature

Date

Page 5 of 5

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