CONFLICTS OF INTEREST

Appendix 1.a.: Declaration Form

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To be sent by the employee to his or her line manager (copying the entity's Compliance Officer)

I, the undersigned:

Mr./Ms. *

Holding the position/duties of *

I hereby declare:

That I am currently not in any potential or actual Conflict of Interest situation.

That I have or may have the following Conflict(s) of Interest:

I undertake to immediately inform my managers of any evolution of this Conflict of Interest.

Two original copies signed in *

Date *

Employee's Signature *

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