This form protects a party from the claim that another party did not know his or her
responsibilities under a code of conduct. This form should be signed by an individual
that is agreeing to abide by an organization’s code of conduct. An executed
acknowledgement form allows a person or company to clearly demonstrate that the
signer was aware of the relevant policies and can help protect an organization from
unnecessary liability. This document can be easily adapted to meet the specific needs
of the user and should be used by entities that have established codes of conduct for
Code of Conduct Receipt and Acknowledgement Form
Name: ________________ [Instructions: print name]
I acknowledge that I have been given a copy of the ________________ [Instructions:
insert name of company or organization setting forth Code of Conduct] (“Entity”) Code
of Conduct and understand that I am expected to read, understand, and adhere to its policies. I
agree to familiarize myself with the material in the Code of Conduct.
I understand that no one other than officers of Entity has the authority to alter this
arrangement or to make any agreement contrary to this policy. I understand that the Company
may change, rescind, modify, or supplement all or part of any policies, practices, procedures,
or benefits described in the Code of Conduct from time to time, in its sole and absolute
discretion, with or without prior notice to me, with the exception of ________________
[Instructions: insert anything that cannot be altered in the future]. When new policies are
added or existing policies or procedures are changed, I understand that the most recent written
policies shall prevail and will govern any new actions taken.
Date: ________________ [Instructions: insert date]
Signed: ________________ [Instructions: insert signature]
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