Principles of Business Conduct Form

Principles of Business Conduct Compliance Certificate

I have read and understand the IEEE Principles of Business Conduct. I will adhere in all respects to the standards described therein. I further confirm my understanding that any violation of the IEEE Principles of Business Conduct will subject me to appropriate disciplinary action, which may include termination of my volunteer/member position or discharge from my staff position.

I certify to IEEE that I am not potentially in violation of the requirements of the program, unless I have noted that potential in a signed Statement of Exceptions (brief written description of the possible violation) attached to this Compliance Certificate.

Please answer the following:

Is a Statement of Exceptions needed?

Yes No

If yes, please enter Statement of Exceptions:

ATTESTATION:
I have entered required responses to the Conflict of Interest Disclosure Statement and Principles of Business Conduct Compliance Certificate to the best of my knowledge and belief.
Are you an IEEE Employee/Volunteer? Yes No
If no, please select checkbox: I have read and understand the IEEE Code of Ethics, particularly as it relates to the potential conflicts of interest noted above - see IEEE web page: http://www.ieee.org/web/membership/ethics/code_ethics.html
Full Name	Date
E-mail
Staff or Volunteer Position
Conference Title and Year (if applicable)
IEEE Location for Staff or Address for Volunteers
City	State/Province
Country	Zip Code (Mail Code)
Telephone Number (Including Area Code or Country and City Code)

A copy of the completed form will be sent to your e-mail for your records. You will be directed to a confirmation page if your form has been submitted successfully.