Whistle-Blower Policy Submission Form
Instructions: Please fill in the information requested below.
| Contact Information (optional): | |
|---|---|
| Name (not required): | |
| Phone (not required): | |
| E-mail (not required): | |
| Address (not required): | |
| City (not required): | |
| State (not required): | |
| Zip (not required): | |
| Describe the complaint in detail: | |||
|---|---|---|---|
| Would you like the committee to follow up with you? | |||
| If yes, how would you like us to follow up? | |||
| If we are following up, please make sure you gave us your information above. | |||
I understand that by making this confidential or anonymous complaint I am doing so in good faith and that I am also free from retaliation, even if it is found that I made this complaint in error. It is also understood that this information will be treated as confidential, and will only be shared with the Audit Committee. I Agree |