Do you understand and support the company’s Code of Ethics?
Yes No ___________
Are you aware of any illegal, unethical or improper practices or
conduct anywhere within this Company?
Yes No ___________
If the answer to the preceding question is "yes", list here,
in full and complete details, all such practices or conduct.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have any threats or promises been made to you in connection with your
answers to the questions on this form?
Yes No ___________
If "yes" please identify them in full and complete detail and
notify company management immediately.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I declare under penalty and perjury, under the laws of the State of __________________,
that the above is true and correct.
Name _________________________ Signature ______________________
Date ___________
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