[Employee name and address]
[Company name and address]
BE IT KNOWN that the undersigned does hereby acknowledge that he/she have read the Company policy statement concerning conflicts of interest, and do hereby declare that neither he/she, nor any member of their immediate family, and/or any other business to which they may be associated with, do have any conflict of interests, and that the proper perťormance of their responsibilities to the Company would be carried out to the very best of their ability.
It is further noted that any deviation would constitute a violation of Company policy. Furthermore, the undersigned does hereby declare that during their employment, they shall continue to maintain all affairs in accordance with the requirements of said company policy.
Signed and dated this ________ day of ________ 20 __.
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