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All potential suppliers / contractors must complete a conflicts of interest declaration at the beginning of
the tender process for appropriate review. In addition, suppliers / contractors must immediately declare
a conflict of interest when it arises or is perceived to arise.
Failing to make the required declarations may prohibit you from conducting business with AngloGold
Ashanti and any existing contracts may be terminated for cause.
Address: _________________________________________________________________________
1. Does any current or former AngloGold Ashanti employee have a financial interest or key role in the
company (senior management, etc.)?
Yes No
If yes, please provide the name of the former AngloGold Ashanti employee/s, his/her previous role/s
at AngloGold Ashanti, and his/her current relationship to your company below:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
2. Is any owner, director or key employee at your company a government official1 or have a close
relationship with a government official?
Yes No
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
3. Does any owner, director or key employee at your company have a current working relationship or
have they worked in the past 2 years with an employee at AngloGold Ashanti?
Yes No
If yes, please provide the names of the relevant owner/director/key employee and the AngloGold
Ashanti employee below and describe the relationship in more detail:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
4. Please provide any other information you consider relevant to disclose under the Policy on Conflicts
of Interest.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Declaration
______________________________________________________________________
Senior Company Representative (including title):
Date: _________________________________________________________________