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Financial Disclosure Form


(For Employees Only)

I, (name of employee), have been advised by XYZ Employer that the Company maintains the highest ethical standards of conduct and expects all employees to use only legitimate practices in commercial operations and in promoting the Company position on issues before governmental authorities.

I acknowledge that I have been advised during the course of my employment not to offer or make directly or indirectly through any person or firm, any payment of anything of value (in the form of compensation, gift, contribution or otherwise) to induce or reward any favorable action by a customer in any commercial transaction or any governmental entity for the purpose of inducing or rewarding action (or withholding of action) by same.

I further acknowledge that I will work exclusively and full-time for XYZ Employer and not own, directly or indirectly, any financial interest in suppliers or customers except for publicly held companies where my interest is less than 1%.

I further agree to report any transactions with suppliers, customers or competitors where I profited personally, and advise XYZ Employer of the value of all gifts (and outside income) received from any source during the course of my employment.

I acknowledge that if XYZ Employer discovers any inaccuracies in the above statements or if I breach any of the representations contained hereinabove, I may be disciplined leading up to or including immediate discharge by XYZ Employer.

Signature of Applicant or Employee: _____________________________
Printed Name of Applicant or Employee: _____________________________
Social Security Number: _____________________________
Date: _____________________________
Name of Witness: _____________________________
Copyright 1998 Steven M. Sack

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