Whistleblower Notification Form

Whistleblower Notification Form

This Whistleblower Notification Form is submitted by Whistleblower Name: employed by/affiliated with Company Name: for the purpose of reporting potential violations of law, company policy, or other misconduct as described below.

Recitals

WHEREAS, the Company maintains policies and procedures obligating employees and other persons to report credible information regarding suspected violations of law, financial impropriety, fraud, corruption, significant safety hazards, or other wrongdoing; and

WHEREAS, the Whistleblower possesses information relevant to alleged wrongdoing and seeks to provide a formal written notification to ensure appropriate investigation, remediation and protection against retaliation; and

WHEREAS, the Company desires to receive, investigate and address allegations promptly while preserving confidentiality to the extent permitted by law.

NOW THEREFORE

In consideration of the mutual covenants set forth below, the Whistleblower and the Company agree as follows:

1. Definitions

For purposes of this Form: (a) "Allegation" means any statement or assertion of possible wrongdoing provided by the Whistleblower; (b) "Investigation" means any fact-finding process initiated by the Company to evaluate Allegations; and (c) "Confidential Information" means information disclosed by the Whistleblower pursuant to this Form and any records, notes, or documentation created by the Company during the Investigation.

2. Details of Allegation

Date(s) of incident (if known): Month Day Year

3. Investigation Procedure

Upon receipt of this Form, the Company will, in good faith, assess and, if warranted, commence an Investigation. The Company will designate an investigator or investigative team, who shall have authority to gather evidence, interview witnesses, and request documents. The Investigation will be conducted promptly, and the Company will use reasonable efforts to complete a review within a commercially reasonable period, subject to the scope and complexity of the Allegation and any legal obligations.

4. Confidentiality and Anonymity

The Company will treat information provided by the Whistleblower as Confidential Information to the extent permitted by law. The Company will limit disclosure of the Whistleblower's identity and the contents of this Form to persons with a legitimate need to know for purposes of the Investigation, legal compliance, or remedial action. Notwithstanding the foregoing, disclosure may be required by law, by court order, or when necessary to protect the legal rights of the Company or others.

Request for anonymity: I request that my identity be kept anonymous to the fullest extent practicable.

5. Non-Retaliation

The Company prohibits retaliation in any form against any person who, in good faith, makes a report or participates in an Investigation. Retaliation includes, but is not limited to, termination, demotion, suspension, harassment, or any adverse employment action. Any alleged retaliation should be reported immediately and will be investigated. Remedies for proven retaliation may include disciplinary action up to and including termination of employment.

6. Cooperation; Access to Records

The Whistleblower agrees to cooperate reasonably with the Company in the Investigation, including making available relevant documents and being available for interviews if requested. The Company reserves the right to access relevant records and systems and to preserve evidence in accordance with applicable law.

7. Certification and Acknowledgment

By signing below, the Whistleblower certifies that the information provided in this Form is true and correct to the best of their knowledge and belief. The Whistleblower understands that knowingly submitting false or malicious information may subject the Whistleblower to disciplinary action or other legal consequences.

8. Notices

All notices, requests, consents and other communications required or permitted under this Form shall be in writing and delivered to the contact information provided by each party. The Company contact for receipt of notices and Investigations:

9. Remedies; Preservation of Other Rights

The remedies available under this Form include Company-initiated corrective actions where appropriate and lawful. This Form does not waive any statutory or common-law rights available to either party. The Whistleblower retains the right to report possible violations to governmental or regulatory authorities as permitted by law.

10. Amendments; Waiver; Counterparts

Any amendment or waiver of any provision of this Form must be in writing and signed by both parties. No failure or delay by either party in exercising any right shall operate as a waiver. This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

11. Governing Law; Entire Agreement; Severability

This Form shall be governed by and construed in accordance with the internal laws of the jurisdiction of the Company's principal place of business without regard to conflict of laws principles. This Form constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior oral and written communications. If any provision of this Form is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

12. Signatures

The parties below acknowledge that they have read, understand, and agree to the terms set forth in this Whistleblower Notification Form.

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