Terminix - Disclosure Form - Conflict of Interest

	♦ First Name M.I. ♦ Last Name
Your Information

	♦ Colleague ID Phone Number (Preferred) Email (Preferred)
	(Format: (###) ###-### + Ext.#) (Format: username@domain.com)

Please Note	Select your Business Unit from the dropdown below. Locations cannot be edited. Once selected, the location information will automatically populate in the boxes below.

	♦ Conflict of Interest Disclosure Type Click the corresponding box for any potential conflict you need to disclose. (Previous disclosures DO NOT have to be re-submitted unless there has been a change in the circumstances.)
Disclosure Type	Check this box if you have a close personal relationship with another Rentokil Terminix colleague. If you have checked this box, please provide the name of the colleague(s) with whom you share a close personal relationship, and describe what type of relationship it is (parent, sibling, in-law, roommate, etc.) in the details section below. Check this box if you have a close personal relationship with a Rentokil Terminix Business Partner (vendor, contractor, distributor, or other third party with whom Rentokil Terminix does business). If you have checked this box, please provide the name of the organization, the name of the person with whom you have a close personal relationship, what type of relationship, and what that individual’s role is within the organization, in the details section below. Check this box if you or someone with who you have a close personal relationship have a relationship with a Rentokil Terminix Franchisee. If you have checked this box, please provide the name of the Franchisee, the name of the person with whom you have the close personal relationship, the type of relationship and where the franchise is located in the details section below. Check this box if you or someone with whom you have a close personal relationship have a relationship with a Rentokil Terminix competitor. (Do not disclose contractual service agreements with national or local competitors such as pest control companies, cleaning services or other similar services used for your residence.) If you have checked this box, please provide the name of the organization, and nature of the business, the name of the person with whom you have a close personal relationship, the type of relationship, and his or her role within the competitor organization in the details section below. Check this box if you are engaged in an outside business activity or outside employment that could potentially create a conflict with your work at Rentokil Terminix. If you have checked this box, please provide the name of the organization and the nature of the business in the details section below. Check this box if you and a member of your management chain or any colleague you manage have a joint relationship with an outside entity. If you have checked this box, please provide the name of the outside entity, the nature of the relationship with the entity and the nature of the entity’s activities. Also provide the name of the Rentokil Terminix colleague with whom you have this joint relationship in the details section below. Check this box if you have a relationship with any outside entity that has not yet been identified in this form. (Do not disclose relationships with religious affiliations or charitable organizations, unless you are an officer within the organization.) If you have checked this box, describe the entity, the type of organization, the nature of the relationship and your role with the entity in the details section below. Check this box to report any potential conflict that does not fit into a category above. If you have checked this box, please describe the potential conflict in the details section below. Check this box if you have no conflicts of interest to report, and enter note in details below (i.e., “none”, or “no conflicts”).

Check this box if you have a close personal relationship with another Rentokil Terminix colleague.

If you have checked this box, please provide the name of the colleague(s) with whom you share a close personal relationship, and describe what type of relationship it is (parent, sibling, in-law, roommate, etc.) in the details section below.

Check this box if you have a close personal relationship with a Rentokil Terminix Business Partner (vendor, contractor, distributor, or other third party with whom Rentokil Terminix does business).

If you have checked this box, please provide the name of the organization, the name of the person with whom you have a close personal relationship, what type of relationship, and what that individual’s role is within the organization, in the details section below.

Check this box if you or someone with who you have a close personal relationship have a relationship with a Rentokil Terminix Franchisee.

If you have checked this box, please provide the name of the Franchisee, the name of the person with whom you have the close personal relationship, the type of relationship and where the franchise is located in the details section below.

Check this box if you or someone with whom you have a close personal relationship have a relationship with a Rentokil Terminix competitor. (Do not disclose contractual service agreements with national or local competitors such as pest control companies, cleaning services or other similar services used for your residence.)

If you have checked this box, please provide the name of the organization, and nature of the business, the name of the person with whom you have a close personal relationship, the type of relationship, and his or her role within the competitor organization in the details section below.

Check this box if you are engaged in an outside business activity or outside employment that could potentially create a conflict with your work at Rentokil Terminix.

If you have checked this box, please provide the name of the organization and the nature of the business in the details section below.

Check this box if you and a member of your management chain or any colleague you manage have a joint relationship with an outside entity.

If you have checked this box, please provide the name of the outside entity, the nature of the relationship with the entity and the nature of the entity’s activities. Also provide the name of the Rentokil Terminix colleague with whom you have this joint relationship in the details section below.

Check this box if you have a relationship with any outside entity that has not yet been identified in this form. (Do not disclose relationships with religious affiliations or charitable organizations, unless you are an officer within the organization.)

If you have checked this box, describe the entity, the type of organization, the nature of the relationship and your role with the entity in the details section below.

Check this box to report any potential conflict that does not fit into a category above.

If you have checked this box, please describe the potential conflict in the details section below.

Check this box if you have no conflicts of interest to report, and enter note in details below (i.e., “none”, or “no conflicts”).

	Business Unit Location
	(Select One)
	Street/Mailing Address
	Search Clear
	City St./Province Zip/Post Code Country

	♦ I hereby affirm that the following statements are true: (Select all that apply)
Acknowledge	I have read and understood the Terminix Code of Conduct and Conflict of Interest Policy.
	I agree to comply with the Code of Conduct and Conflict of Interest Policy.
	The information contained in this form is true and accurate to the best of my knowledge and belief.

Colleague

Potential Conflicts of Interest Disclosure Details

Acknowledgement, Follow-up and Submission

	List the first and last name of up to three involved parties here (limit 1 name per field below).
Involved Parties

	♦ Please provide the details for the questions you answered “Yes” to above (by clicking the corresponding box).
Details