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发表于 2012-1-13 11:52:00
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document 3: 后面的文件待发
I, ______________________ (state your name), _________________ (state your nationality), of legal age, _________ (single/married), and residing at _________________________________________________, after having been duly sworn to in accordance with law hereby depose and say that:
1. I am an officer of ____________________ (state the name of company for accreditation) being its ____________________ (state the position or level, etc);
2. Our agency has an existing and/or intended business dealing with ________ (indicate which member of the “XX Group”, i.e., XXT, XXand its subsidiaries and affiliates) as a provider of ______________________________, commencing on _______________ and ending on _______________ as documented in a Contract of Service, Purchase Order, and/or Memorandum of Agreement dated _______________;
3. In the interest of transparency and in compliance with the XX Group’s Corporate Governance Policies especially the Conflict of Interest Policy, I hereby disclose the following (please mark with a check if applicable and state the name/s of persons concerned; mark with “x” if not applicable):
(__) That I have financial involvement with a XX Group Director, Employee or Consultant;
(__) That I have existing or previous close personal or business affiliation or relationship with a XX Group Director, Employee or Consultant (Specifics of the relationship: ______________________________);
(__) That only the following company director/s, officer/s, major stockholder/s, incorporator/s are former employees of the XXX Group and that their last position held and date of separation are summarized in the table below.
NAME OF DIRECTOR, OFFICER OR MAJOR STOCKHOLDER, INCORPORATOR DATE OF SEPARATION FROM PLDT GROUP LAST POSITION HELD AS EMPLOYEE OF THE PLDT GROUP
(__) That I have the following 3rd degree relatives in the XXX Group, by consanguinity, affinity or legal adoption (please indicate by putting a check mark);
[__] spouse,
_______________________________________
[__] parents,
______________________________________
[__] children and their spouses,
______________________________________
[__] siblings and their spouses,
______________________________________
[__] nieces and nephews and their spouses (limited to children of siblings),
______________________________________
[__] grandparents,
______________________________________
[__] aunts and uncles (limited to sisters or brothers of parents),
______________________________________
[__] domestic partner and his/her 3rd degree relatives by consanguinity, affinity or legal
adoption,
______________________________________
[__] others, _______________________
______________________________________
(__) That only the following company incorporators, directors, officers and major stockholders* are related to directors, employees or consultants of [XX Group] listed opposite thereto up to the 3rd degree of consanguinity, affinity or legal adoption:
SUPPLIER / CONTRACTOR XXX GROUP
RELATIONSHIP
NAME OF DIRECTOR, OFFICER OR MAJOR STOCKHOLDER* POSITION NAME OF DIRECTOR, EMPLOYEE OR CONSULTANT POSITION
* (1) of a corporation/firm where a [XXX Group] Director/Employee/Consultant and/or his Relative, either singly or collectively, holds/owns more than ten percent (10%) of the subscribed capital or equity of such corporation/firm; or (2) of a corporation/firm wholly or majority owned or controlled by the corporation/firm, where a [XXX Group] Director/Employee/Consultant and/or his Relative, either singly or collectively, holds/owns more than ten percent (10%) of the subscribed capital or equity of such corporation/firm.
(__) That only the following company director/s, officer/s, major stockholder/s, incorporator/s are concurrently among the incorporator/s, director/s, officer/s, major stockholder/s of a company which is among the XXX Group’s roster of vendors. Details are summarized in the table below.
NAME OF DIRECTOR, OFFICER OR MAJOR STOCKHOLDER, INCORPORATOR POSITION INVOLVEMENT WITH OTHER VENDOR/S OF THE PLDT GROUP
COMPANY NAME POSITION /
% OWNERSHIP
(__) That no incorporator, director, officer or major stockholder (or general partner if a partnership) of ________________________ (state the name of agency or third-party business partner) is a former employee of the XXX Group; or is an affiliate or is related to any director, employee or consultant of the XXX Group up to 3rd degree of consanguinity, affinity or legal adoption; or has involvement with other vendor/s of the XXX Group.
4. In the event that I would become aware of any such relationship or affiliation in the duration of my contractual relationship with any member of the XXX Group, I would immediately disclose this to Vendor Management Office;
5. I am willing to take further steps, actions or measures to comply with other requirements as may be prescribed by the XXX Group such as, but not limited to, periodic declaration of relationships and/or affiliations with any XXX Group director, officer, employee, or consultant or their relatives;
6. I acknowledge the authority of the XXX Group to determine and impose the appropriate sanction in the event of my violation or non-compliance with its Conflict of Interest Policy which may include, but not limited to, the immediate termination of the contractual relationship;
7. I executed this affidavit to attest to the truth of the foregoing and as part of the documentary requirements for my official business dealing with the XXX Group.
IN WITNESS WHEREOF, I have affixed my signature this ___ day of ____________ 20___ at
_______________________.
_________________________
Affiant
SUBSCRIBED AND SWORN TO before me, this ____ day of __________ 20___, affiant exhibited to me the following Competent Evidence of Identity:
Name Competent Evidence of Identity
(Passport, Driver’s License, SSS/GSIS/Voter’s ID, etc) Date
Doc. No. ________;
Page No. ________;
Book No. ________;
Series of ________.
有一种快乐叫做眉毛永远不在一条线上， 你懂的！ |
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发表于 2012-1-13 11:41:00
