Employee Supplier Application

EMPLOYEE SUPPLIER APPLICATION

This application is submitted by an individual who is employed by the Company and seeks approval to provide goods or services to the Company as a supplier. Completion of this form is a certification that the information provided is true, that any potential conflict of interest has been disclosed, and that the applicant consents to verification of the information and to background and reference checks as described in the Certification and Authorization section below.

Personal Information

Employment Information (as Employee)

Employment Start Date:

Supplier / Business Information

Licenses, Certifications & Insurance

Conflict of Interest & Disclosure

Are you a current employee of the Company?    If yes, provide your Company employee ID (if applicable):

Do you or any immediate family member have a financial interest in the supplier business? Yes No

List any relatives or household members employed by the Company and their relationship and department:

Employment History

Education

Professional References (Three Required)

Legal Disclosures & Company Policies

At-Will Employment: I acknowledge that my status as an employee is at-will and that supplying goods or services to the Company does not alter my at-will employment status, create any form of partnership, joint venture, or change the terms and conditions of my current employment unless an authorized written agreement states otherwise.

Equal Opportunity: The Company is an equal opportunity employer and evaluates supplier approvals based on objective vendor qualification criteria. No approval shall be granted in violation of the Company's nondiscrimination obligations.

Confidentiality & Intellectual Property: Any proprietary information or deliverables produced under a future supplier engagement will be subject to Company confidentiality and intellectual property terms to be set out in a separate purchasing or services agreement.

Authorization, Background Checks & Certification

By signing below I certify under penalty of disciplinary action and potential legal remedies that all statements contained in this application are true, complete and accurate to the best of my knowledge. I understand that falsification, omission, or misstatement of material facts may result in denial of supplier approval and/or disciplinary action up to and including termination of employment.

I authorize the Company and its authorized agents to verify any information provided in this application, to contact my listed references and former employers, and to obtain background checks and other screening reports as permitted by law. I further consent to the release of information by prior employers and references for the purposes of evaluating this application.

I understand that no purchase order, contract, or work may commence until I am formally approved as an authorized supplier by the Company's procurement or authorized designee and a written agreement or purchase order is executed.

Applicant Initials acknowledging disclosures:

Applicant Certification

I certify that I have read and understand the statements and policies above. I affirm that I have disclosed any potential conflicts of interest and that I will notify the Company promptly of any changes that may affect my eligibility to provide goods or services. I understand that approval as an employee-supplier is subject to ongoing compliance with Company policies, completion of required insurance and tax documentation, and execution of any required supplier agreements.

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