Employee Disclosure of Interest

EMPLOYEE DISCLOSURE OF INTEREST

Purpose: This Employee Disclosure of Interest documents current and potential conflicts between the employee's outside interests and the interests of the organization. Employees must disclose any financial interests, outside employment, board service, family relationships with vendors or clients, receipt of gifts or payments, or other activities that could reasonably be perceived to affect impartial performance of duties. Disclosures must be accurate and updated within 30 days of any material change.

Personal Information

Full Legal Name:

Phone:    Email:

Position Information

Reporting Manager:    Start Date (with employer):

Full-time    Part-time    Contractor

Disclosure Questions (Mark all that apply and provide details)

1. Outside Employment or Consulting: I perform or will perform services for another employer, client, or business. If selected, provide full details.

2. Ownership Interests: Ownership, stock, or financial interest in any entity that does business with or competes with the company. If selected, identify the entity and nature/extent of interest.

3. Board Memberships or Advisory Roles: Service as a director, officer, trustee, or paid advisor for any outside organization. If selected, list organization, position, and time commitment.

4. Family Relationships with Vendors or Clients: Family members or household members employed by, owning, or materially affiliated with any vendor, supplier, or client. If selected, identify person, relationship, and entity.

5. Gifts, Honoraria, or Payments: Receipt of payments, gifts, travel, entertainment, or honoraria from any person or organization that seeks to do business with the company or is in competition. If selected, specify source and value (per item).

6. Use of Company Resources for Outside Activities: Use of company facilities, equipment, data, or time to support outside employment, consulting, or business interests. If selected, explain scope and frequency.

Financial Interests and Transactions

List any business, investment, loan, guarantee, or other financial arrangement with entities that do business with or compete with the company. Include approximate value or percentage ownership where known.

Employment History (Most Recent)

Title:    Dates Employed:

Previous Employment

Title:    Dates Employed:

Education

Professional References

Legal Disclosures and Acknowledgments

At-Will Employment: Nothing in this disclosure alters the at-will employment relationship, if applicable. The company may terminate employment at any time, with or without cause, unless otherwise provided in a separate written agreement signed by an authorized representative.

Equal Opportunity: The company is an equal opportunity employer. Decisions regarding employment are based on business needs, job requirements, and individual qualifications, without unlawful discrimination.

Duty to Disclose: I understand I have an ongoing duty to disclose any material change to the information provided herein within 30 days of the change. Failure to disclose may result in corrective or disciplinary action, up to and including termination.

Confidentiality: Disclosures will be treated as confidential to the extent practicable and consistent with legal, regulatory, and company requirements. The company may share relevant information with investigators, legal counsel, or other departments when necessary to evaluate or mitigate a conflict.

Authorization to Verify: I authorize the company and its authorized agents to verify the information provided, including contacting prior employers, references, business associates, or other entities identified in this form, and to obtain background information where permitted by law.

Applicant Certification

I certify that all statements in this disclosure are true, accurate, and complete to the best of my knowledge. I acknowledge that omission or misrepresentation of facts may be grounds for disciplinary action, up to and including termination. I further acknowledge that submission of this form does not alone determine whether a conflict exists; the company will review and, if necessary, recommend actions to avoid or mitigate conflicts.

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