Conflict of Interest Declaration Form
IVL expects and intends that all its employees to act in a legal and ethical manner, and wants our dealings with our customers, suppliers and competitors to build long-term trust and reputation for quality, service and integrity. This questionnaire is intended to help us identify any issues that should be discussed. A “yes” answer to any question is not necessarily a violation of Company policy, but requires the employee to describe the situation in writing, and for the Company to understand and discuss the matter with the employee.
Enter your first and last names below
First Name
Last Name
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
-
Month
-
Day
Year
Date
Associate Signature. You may complete this with your touch screen, mouse or touch pad.
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Should be Empty: