Please tell us who you are:

Full Name *

Company *

Designation *

likert scale test

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Agree
Disagree

date

SECTION 1: ANNUAL BOARD SURVEY

A rating of "1" is deemed "Average" , a rating of "2" is "Good" and a rating of "3" is "Excellent". Where a rating of "1" is given, kindly add an explanation (with suggestions for improvement where possible) in the "Comments" section provided.

1. Planning

1.1 The Board determines and reviews the strategic direction on an on-going basis.

1. Average

2. Good

3. Excellent

Comment:

1.2 The Board has a good understanding of strategy and business plans.

1. Average

2. Good

3. Excellent

Comment:

1.3 The Board annually considers the budgets, obtaining an appreciation of the key performance indicators and other pertinent issues from the management team, before approving each annual budget.

1. Average

2. Good

3. Excellent

Comment:

2. Risk Assessment

2.1 The management reports and annual review provide a sufficient balance between financial and operating issues to obtain an informed perspective of performance and operations.

1. Average

2. Good

3. Excellent

Comment:

2.2 The Board is satisfied that adequate corporate responsibilities are being fulfilled as set out in the Memorandum of Incorporation and as determined by the Board.

1. Average

2. Good

3. Excellent

Comment:

2.3 The Board is satisfied that all relevant legislation, governance and other regulations governing its conduct and operations are in order.

1. Average

2. Good

3. Excellent

Comment:

SECTION 2: ANNUAL DECLARATION OF INTEREST

The intention of this declaration is to disclose any possible personal, familial or business relationship that reasonably could give rise to a conflict of interest, potential conflict of interest or the appearance of a conflict of interest. The purpose of completing this section is to acknowledge that he or she is acting in accordance with the letter and spirit of Good Corporate Governance by pledging their personal commitment.

2.1 Please note any business interests (shareholdings in other product suppliers, personal interests, family interests, directorships, consultancy, paid employment, other affiliations with other parties to a business transaction) that may give rise to a potential conflict of interest.

2.2 Would you be able to confirm if the FSP you represent has acquired any material financial interests or more than 30% remuneration (which includes any commission) from the product supplier.

2.3 Would you be able to confirm if you (in your personal capacity) have acquired any material financial interests or more than 30% remuneration (which includes any commission) from the product supplier.

2.4 Please disclose any Non-cash Incentives which could be viewed as a potential conflict of interest. Please list any such receipts in the last 12 months (eg. gifts, incentive trips, sponsorships, business services, entertainment, preferential or differentiated services, shareholdings, sales quota obligations, product biases ect).

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Impact Tracker Subscription Form

Impact Tracker Subscription Form

Association for Savings & Investment SA

ASISA Enterprise and Supplier Development

ASISA Foundation

ASISA Academy