NCD Alliance membership renewal conflict of interest declaration

NCD Alliance (NCDA) requires that all members complete the annual self-declaration form on Conflict of Interest upon renewing their membership, according to the NCDA Membership Conflict of Interest Policy.

If you have any questions about this form, please contact membership@ncdalliance.org.

Member organisation

Organisation name

New organisation name

Conflict of interest declaration

I certify that any of my organisation’s interests are not in contradiction with any of NCDA’s interests and goals, in particular that my organisation is not funded, sponsored, supported, or influenced by the alcohol, tobacco and nicotine, ultra-processed and HFSS foods & beverages, fossil fuel extraction or arms industries, or any other Tier 1 industries in the NCDA Organisational Conflict of Interest Policy.

I have NO CONFLICT of interest to declare

I have a conflict of interest to declare

I declare that the above information is true to the best of my knowledge and agree to disclose immediately if there is a change to the above information or if it becomes inaccurate.

The above information IS accurate

The above information IS NOT accurate

Please provide any further comments or statement related to your organisation's disclosure of any Conflict of Interest.

Disclosure agreement

I agree that the information received from my organisation is provided 'as is', with a guarantee of completeness and accuracy. NCDA assumes no responsibility or liability for any errors or omissions in the aforesaid declaration of conflict of interest of NCDA members.

I agree

I do not agree

Contact information

Name Prefix

First Name

Last Name

Job Title

Signature

Sign above

Date