Whistleblower Report

WHISTLEBLOWER REPORT AND REPORTING AGREEMENT

Reporter Name:   Company Name:

RECITALS

WHEREAS, Reporter is providing information to Company concerning alleged violations of law, company policy, or serious misconduct that may materially affect the Company or its stakeholders; and

WHEREAS, Company maintains an internal reporting procedure and commits to evaluate and, where appropriate, investigate reported matters in accordance with the terms set forth below; and

WHEREAS, Reporter desires to supply details of alleged wrongdoing and, subject to the conditions herein, may be eligible for consideration of a reward or other remedial measures as provided in this Agreement.

REPORTER INFORMATION

Current employee Former employee Contractor/Consultant Other

REPORT DETAILS

Date(s) of alleged act(s):    Location of alleged act(s):

Fraud or financial impropriety Regulatory non-compliance Safety or environmental hazard Discrimination or harassment Other

SCOPE OF ALLEGATION / SCOPE OF WORK

PAYMENT TERMS (REWARDS / INCENTIVES)

Reward Amount (if eligible):   Payment Schedule:

Payment Conditions: Reporter acknowledges that any reward is contingent upon verification of the allegation, Company’s determination of recoverable amounts or remedial benefit, compliance with applicable law, and receipt of any documentation required by Company. Payments, if any, will be subject to required tax reporting and withholding as determined by law.

TERM AND TERMINATION

Agreement Start Date:   Agreement End Date:

Termination for Cause: Company may terminate this reporting arrangement for material breach, willful misrepresentation by Reporter, or where continuation of the evaluation would be unlawful. Termination does not affect obligations that by their nature survive termination, including confidentiality and indemnity provisions.

CONFIDENTIALITY

Company will use reasonable efforts to maintain the confidentiality of the Reporter’s identity and the contents of this report to the extent permitted by law and necessary to investigate and remediate the alleged conduct. Company reserves the right to disclose information to legal counsel, regulatory authorities, auditors, or law enforcement as required by applicable law. Reporter acknowledges that absolute confidentiality cannot be guaranteed where disclosure is required by law or necessary to protect the public interest.

CERTIFICATION AND ACKNOWLEDGMENT

By submitting this report, Reporter certifies under penalty of law that, to the best of Reporter’s knowledge, the information provided herein is true, correct, and complete. Reporter understands that making a materially false or knowingly fabricated report may subject Reporter to disciplinary action and legal penalty under applicable law.

Reporter hereby consents to Company conducting inquiries and investigations reasonably necessary to evaluate the report and to use and disclose information provided in connection with such investigation as described in the Confidentiality section.

GOVERNING LAW

This Agreement and any claim or controversy arising out of or relating to it shall be governed by and construed in accordance with the laws of the jurisdiction specified below without regard to its conflicts of law principles.

ENTIRE AGREEMENT

This document embodies the entire agreement between Reporter and Company with respect to the subject matter hereof and supersedes all prior or contemporaneous representations, understandings, and communications, whether written or oral. Any amendment or waiver shall be effective only if in writing and signed by both parties.

ADDITIONAL INFORMATION

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