Employee Incentive Nomination Form

EMPLOYEE INCENTIVE NOMINATION FORM

Personal Information

Full legal name:

Hire date:

Position Information

Reporting manager:

Employment status: Full-time Part-time Temporary/Contract

Start date in current role:

Employment History (Most Recent)

Title:   Dates: to

Employment History (Prior)

Title:   Dates: to

Education

Graduation date:

Professional References (3)

Phone:   Email:

Phone:   Email:

Phone:   Email:

Incentive Nomination Details

Type of incentive (select all that apply):

Monetary bonus   Paid time off   Gift card or merchandise   Equity/Stock   Other

Proposed monetary amount:

Proposed time off (if applicable):

Performance Impact and Metrics

Performance period start:   end:

Estimated financial impact (if applicable):

Prior Awards and Eligibility

Has the nominee received an incentive award in the last 12 months? Yes No

Supporting Documentation

Manager Recommendation (for review only)

Recommendation: Recommend Recommend with modification Do not recommend

Manager review date:

Legal Disclosures and Applicant Certification

At-Will Employment: Submission of this nomination does not alter the nominee's employment status. Employment remains at-will and may be terminated by either party at any time, with or without cause or notice, unless otherwise provided by a valid written agreement signed by an authorized representative.

Equal Opportunity: The company considers nominations and all personnel actions without regard to protected characteristics and evaluates incentives based on objective criteria and documented performance.

Tax and Reporting: Any incentive awarded may be subject to applicable taxes and reporting. The recipient is responsible for taxes as required by law; the company will report awards in accordance with applicable tax and payroll requirements.

Authorization to Verify: By signing below, the nominator certifies that the information provided is true and complete to the best of their knowledge, authorizes verification of employment and performance records as necessary, and consents to any routine background or reference checks required for award approval.

I certify that all information submitted on this form and accompanying documentation is accurate and complete, and I understand that falsification may disqualify the nominee and subject me to disciplinary action.

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