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Employee Name:

Title/Job Description:

Employment End Date:

Forwarding Address:

New Employer:

Interview Conducted By:

I, the undersigned employee of [company] (the “Company”), hereby certify that I have in my possession no documents, photographs, diagrams, computer software or any other material containing trade secrets or confidential information of the Company, including but not limited to formulae, technical information, customer lists, supplier lists, and procedural information, whether prepared by me or otherwise.

I further certify that should any such documents, photographs, diagrams, computer software or any other material come into my possession, I will be promptly deliver them to the Company, and I will neither retain any duplicates or copies, nor deliver any duplicates or copies to another.

I acknowledge that my obligation to the Company to maintain in confidence all trade secrets and confidential information of the Company, and to not disclose or make use of such information, continues even though I will no longer be employed by the Company.

I acknowledge my , 199 agreement with the Company to not engage in or solicit others to engage in competition with the Company or accept employment with any competitor in [geographic area] for a period of [time period].

Dated: Signed:

Name:

 For the Company Signed:

Name: