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BUSINESS ETHICS AND CONDUCT
DISCLOSURE STATEMENT




Are you familiar with and do you support the companys Code of Ethics?

Yes      No    


Are you aware of any illegal, unethical or improper practices or conduct anywhere within this Company?
  
Yes      No    


If the answer to the preceding question is "yes", list here, in full and complete details, all such practices or conduct. (Use additional pages if necessary.)
                                                                                                        


Have any threats or promises been made to you in connection with your answers to the questions on this form?

Yes      No    


If "yes" please identify them in full and complete detail and notify company management immediately.
                                                                                                        



I declare under penalty and perjury, under the laws of the [State/Province] of [STATE/PROVINCE] that the forgoing is true and correct. Executed this [DAY] day of [MONTH], [YEAR], at [PLACE].


EMPLOYEE            COMPANY



                          
Authorized Signature  Authorized Signature

                          
Print Name and Title          Print Name and Title


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