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2024 IVMS Conflict of Interest Declaration Form
This digital form will help to improve the effectiveness and efficiency of employee record completion and retrieval.
Employee Name
*
First
Last
Position
Department/Division
I. POTENTIAL CONFLICTS IN WORKING
Do you, or does any member of your immediate family, have a full or part time job with, or do business with, a competitor of the Company, or with a customer, a potential customer, a supplier or a potential supplier to the Company?
Yes
No
Have you accepted a gift from a competitor, customer, a potential customer, a supplier or potential supplier to the Company, other than a meal or a gift of nominal (approximately $86 USD) value?
Yes
No
II. POTENTIAL CONFLICTS IN OWNERSHIP
Do you, or does any member of your immediate family, have a financial interest in any competitor of the Company, or with a customer, a potential customer, a supplier or a potential supplier to the Company?
Yes
No
III. OTHER MATTERS.
In your best judgment, is there any situation which makes it difficult for you to perform your job for the Company with complete loyalty and that should be understood and discussed with the management of the Company?
Yes
No
Any “yes” answer should be disclosed and described in writing below.
Please identify the personal interest(s) that may affect or be seen as having an impact on your ability to carry out your duties honestly.
Date Completed
MM
/
DD
/
YYYY
Associate Signature. You may complete this with your touch screen, mouse or touch pad.
*
Clear