EmailMe Form - Conflict of Interest Declaration Form

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 *

Clear