Employee Release and Waiver Form

EMPLOYEE RELEASE AND WAIVER FORM

Parties and Effective Date

Employee Name:

Employer Name:

Effective Date of Release:

Personal Information

Position Information

Date Hired:    Separation/End Date:

Employment History (Most Recent)

From:    To:

Employment History (Previous)

From:    To:

Education

Graduation Date:

References

Legal Disclosures and Notices

At-Will Employment Statement: Employee acknowledges that prior to execution of this Release and Waiver, the employment relationship with Employer is at-will and may be terminated by either party at any time, unless otherwise set forth in a separate written agreement.

Equal Opportunity Statement: Employer represents that it is an equal opportunity employer and that the consideration offered under this Release is not conditioned on any protected characteristic.

Authorization and Certifications

Authorization to Contact: Employee authorizes Employer and its agents to contact prior employers and listed references for purposes of verifying employment history and to conduct any background checks required to effectuate the obligations under this Release. Employee hereby releases those parties from liability for providing truthful information.

Release, Waiver and Related Terms

General Release: In consideration of the monetary and non-monetary consideration set forth in this document, Employee, on behalf of Employee and Employee's heirs, assigns, agents and representatives, fully and forever releases and discharges Employer and its current and former officers, directors, employees, agents, subsidiaries and affiliates from any and all claims, demands, causes of action, liabilities and damages, whether known or unknown, suspected or unsuspected, that Employee has or may have arising out of or related to Employee's employment or separation from employment through the Effective Date.

Scope of Claims Released: The foregoing release includes, but is not limited to, claims for wages, bonuses, benefits, discrimination, retaliation, wrongful termination, breach of contract, tort, statutory claims under applicable federal or state employment laws and any claims for emotional distress or punitive damages, except as limited below.

Exceptions and Limitations: This Release does not waive Employee's rights to vested benefits under qualified benefit plans, rights to unemployment compensation, rights arising after the Effective Date, claims that cannot be waived by law, or rights to file a charge with a governmental agency where such waiver is prohibited. Employee acknowledges that Employee has read this paragraph and understands its limitations.

Waiver of Unknown Claims: Employee expressly waives the benefit of any statute or rule that would otherwise limit a release to claims known at the time of execution, and acknowledges that Employee may later discover facts different from or in addition to those Employee presently knows, and nevertheless agrees that this Release shall be effective with respect to such additional or different facts.

Confidentiality and Non-Disparagement: Employee agrees to keep the terms and amount of this Release confidential and not to make any false or disparaging statements, written or oral, about Employer, its officers, directors or employees. Employee acknowledges that breach of confidentiality or non-disparagement may result in injunctive relief and damages.

Return of Company Property: Employee represents that all Employer property has been returned. Employee agrees to immediately return all remaining Employer property and to cooperate in completing the return. Employer may set off amounts owed for unreturned property from amounts payable under this Release to the extent permitted by law.

Tax Withholding: Employer will withhold taxes as required by law from any payments made pursuant to this Release. Neither Employer nor any related entity provides tax advice; Employee is encouraged to consult a tax advisor regarding tax consequences of any payment or benefit provided under this Release.

Indemnification: Employee agrees to indemnify and hold Employer harmless from any claims, liabilities or losses arising out of Employee's breach of this Release, including reasonable attorneys' fees incurred by Employer in enforcing this Release.

Non-Admission of Liability: The parties agree that this Release does not constitute an admission of liability or wrongdoing by Employer and that any payments are made solely for the purpose of resolving disputes and avoiding litigation.

Governing Law and Venue: This Release shall be governed by the substantive laws of the state in which the Employer's principal place of business is located, without regard to conflict-of-law principles. Any dispute arising under this Release shall be brought exclusively in the state or federal courts located in that jurisdiction.

Severability: If any provision of this Release is determined to be invalid or unenforceable, the remainder of the Release shall remain in full force and effect and such provision shall be reformed to the minimum extent necessary to make it enforceable.

ADEA / Age-Related Notice (If Applicable)

Age Disclosure: The Age Discrimination in Employment Act provides special requirements for releases of age discrimination claims by persons 40 years of age or older. If Employee is age 40 or older, Employee acknowledges receipt of this notice and the opportunity to consider the terms of this Release for the period permitted by law and to consult with an attorney prior to signing.

Employee Certification and Acknowledgement

I certify that I have read this Release and Waiver in its entirety, that I understand its terms, that I have been given a reasonable opportunity to review and consider it, and that I enter into it knowingly, voluntarily and without coercion. I represent that the information provided in this form is true and complete to the best of my knowledge. I understand that I may consult with counsel of my choice prior to signing.

Acknowledgment of Consideration

Employee acknowledges receipt of the consideration described above, including any severance payments, continuation of benefits or other non-monetary terms, in exchange for the promises and releases contained herein. Employee acknowledges that acceptance of the consideration is conditioned upon execution of this Release.

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