在新加坡，Consent to Act as Director and Statement of Non Disqualification to Act as Director是潜在董事作出的声明，表明其满足相关要求，未违反任何取消资格规定，是接受公司董事职务之前必须签署的文件。中文可按字面意思译为“出任董事职位同意书以及非丧失担任董事资格声明”。

具体内容如下所示：

Name of Company:

公司名称：

Company No:

公司编号：

I, the undermentioned person, hereby consent to act as a director of the abovenamed company with effect from ……………… (date) and declare that:

本人，即下述签署人，特此同意自……………… (日期)起担任上述公司董事。同时，本人声明：

(a) I am not disqualified from acting as a director, in that:

(a) 本人并未丧失担任董事之资格，原因如下：

(i) I am not below 18 years of age and that I am otherwise of full legal capacity.

(i) 本人已满18岁，具有完全法律行为能力。

(ii) Within a period of 3 years preceding the date of this statement I have not had any disqualification order made by the High Court of Singapore against me under section 149A(1) of the Companies Act (“the Act”).

(ii) 在本声明作出之日前3年内，本人未收到新加坡高等法院依据《公司法》（“《法案》”）第149A(1)条向本人发出的取消资格令。

(iii) Within a period of 5 years preceding the date of this statement I have not had any disqualification order made by the High Court of Singapore against me under section 149(1) or 154(2) of the Act.

(iii) 在本声明作出之日前5年内，本人未收到新加坡高等法院依据《法案》第149A(1)条或第154(2)条向本人发出的取消资格令。

*(iv) That within a period of 5 years preceding 12th November 1993 I have not been convicted whether within or without Singapore, of any offence —

*(iv) 在1993年12月12日前5年内，本人未在新加坡境内或境外被判犯有以下罪行—

(A) in connection with the promotion, formation or management of a corporation;

(A) 有关公司推广、成立或管理的罪行；

(B) involving fraud or dishonesty punishable on conviction with imprisonment for 3 months or more; or

(B) 涉及欺诈或不诚实行为而可判处3个月或以上监禁的罪行；或者

(C) under section 157 (failure to act honestly and diligently as a director or making improper use of company information for gain) or under section 339 (failure to keep proper company accounts books) of the Act.

(C) 《法案》第157条（未能诚实勤勉地履行董事职责或不当使用公司信息谋取利益）或第339条（未能妥善备存账簿）提及的罪行。

*(v) That within a period of 5 years preceding the date of this statement I have not been convicted, in Singapore or elsewhere, of any offence involving fraud or dishonesty punishable on conviction with imprisonment for 3 months or more.

*(v) 在本声明作出之日前5年内，本人未在新加坡境内或境外被判犯有涉及欺诈或不诚实行为而可判处3个月或以上监禁的罪行。

(vi) That —

(vi) 另：

(A) I have not been convicted of 3 or more offences under the Act in relation to the requirements on the filing of returns, accounts or other documents with the Registrar of Companies and have not had 3 or more orders of the High Court of Singapore made against me under section 13 or 399 of the Act in relation to such requirements;

(A) 本人未因违反《法案》有关向公司注册处提交申报表、账目或其他文件的要求而被判犯有3项或以上罪行，且未收到新加坡高等法院依据《法案》第13条或第399条就该等要求向本人发出的3项或以上命令；

(B) the last of any such conviction did not take place or the last of any such order was not made during the period of 5 years preceding the date of this statement; and

(B) 在本声明作出之日前5年内，本人未被判有任何该等罪行，也未收到任何该等命令；以及

(C) I am not an undischarged bankrupt under section 148(1) of the Act.

(C) 本人并非《法案》第148(1)条项下的未解除债务之破产人。

(vii) By virtue of the foregoing I am not disqualified from acting as a director of the abovenamed company.

(vii) 基于前述声明，本人并未丧失担任上述公司董事之资格。

(b) I am aware of and undertake to abide by my duties, responsibilities and liabilities specified in the Act as well as under the common law where applicable, including the following key administrative and substantive duties, that is, to:

(b) 本人了解并承诺履行《法案》及普通法（若适用）对本人规定的职责、责任和义务，包括下列主要行政职责和实质职责：

(i) discharge my responsibilities in the company;

(i) 履行本人在公司的职责；

(ii) ensure that I have a reasonable degree of skill and knowledge to handle the affairs of the company;

(ii) 确保本人具备合理程度的技能和知识，可以处理公司事务；

(iii) act honestly and be reasonably diligent in discharging my duties and act in the interest of the company without putting myself in a position of conflict of interest;

(iii) 诚实行事，合理勤勉地履行本人职责，为公司利益行事，不将自己置于利益冲突之中；

(iv) employ the powers and assets that I am entrusted with for the proper purposes of the company and not for any collateral purpose;

(iv) 将委托予本人的权力和资产用于公司相关的正当目的，而不是任何附带目的；

(v) ensure that the company and I comply with all the requirements and obligations under the Act including those in respect of meetings, requisitions, resolutions, accounts, reports, statements, records and other documents on the company, filing and notices and any other prerequisites; and

(v) 确保公司和本人遵守《法案》规定的所有要求和义务，包括与公司会议、请求、决议、账目、报告、报表、记录和其他文件、备案和通知及其他先决条件有关的要求和义务；以及

(vi) account to the shareholders for my conduct of the affairs of the company and make such disclosures that are incumbent upon me under the Act.

(vi) 就本人处理公司事务的行为向股东作出解释，并依据《法案》在本人职责范围内进行相关披露。

(c) That —

(c) 另：

*(i) I have read and understood the above statements; or

*(i) 本人签署本表格之前已阅读并理解上述声明；或

*(ii) the above statements were interpreted to me in

……………………………………………………

(state language/dialect)

by…………………………………………………

(state name)

NRIC NO: ……………………………………….

before I executed this form and I confirm that the statements are true. I am also aware that I can be prosecuted in Court if I willfully give any information on this form which is false.

*(ii) 本人签署本表格之前，上述声明已由

…………………………………………………

             （填入姓名）

身份证号码：……………………………………….

用……………………………………………………

（填入语言/方言）

向本人作出解释，且本人确认上述声明属实。此外，本人了解，若本人故意在表格上填写错误信息，本人将被控上庭。

Name: ………………………………………………………………...

姓名：………………………………………………………………...

Address: ………………………………………………………………

地址：………………………………………………………………

*NRIC/Passport No: ………………………. Nationality: …………... Signature: ……………..

*身份证号码/护照号码：………………………. 国籍：…………... 签字：……………..

Dated this ………. day of ……………., ……….

日期：   年   月   日

* Delete where inapplicable.

* 删除不适用的部分。