ENERGY NORTHWEST

CODE OF ETHICS QUESTIONNAIRE
Name of Employee: / Job Title:
Org Code: / Date:
Personal Relationships
  1. Do you have a Personal Relationship (defined in GBP-LEG-01)? Yes No
  2. If Yes, please describe the nature of the Personal Relationship, name of the person, and department they work in.

Financial Interest
  1. Are you or any members of your family* involved in any contract, arrangement, understanding or Financial Interest (defined in GBP-LEG-01)? (*Please include those family members listed in the definition of Personal Relationship in GBP-LEG-01.)
Yes No
  1. Do you or any members of your family have any Financial Interest (defined in GBP-LEG-01) in a firm, corporation, limited liability company, or other legal entity proposing to do business with Energy Northwest? Yes No
In the event you answered “YES” to any of the above questions, please describe all facts and circumstances concerning the nature of your interest or your family’s financial interest, including the name of the entity or organization and the relationship to Energy Northwest.
Outside Employment
  1. Are you, or are you planning to become engaged in Outside Employment as discussed in GBPLEG01? Yes No
  2. If yes, please identify:

  • dates of employment;

  • the (potential) employer or, if self-employed, the name of the business;

  • the type of work to be performed;

  • any potential problems you perceive the outside employment may cause with EN; and any actual or perceived competition or conflicts of interest with EN employment.

Gifts
  1. Have you accepted a Gift (defined in GBP-LEG-01)? Yes No
  2. If yes, please identify the date the Gift was accepted and provide a description of the Gift and the actions you have taken.

Conflict of Interest
  1. Are you aware of any circumstance(s) affecting you (not previously identified) which, now or in the future, may present a Conflict of Interest (defined in GBP-LEG-01) with respect to Energy Northwest? Yes No
  2. If Yes, please describe the nature of the conflict or potential conflict of interest.

Other Ethical Concerns as set out in GBP-LEG-01?
My signature below certifies that I have read and understand GBP-LEG-01 titled, “Code of Ethics”, that I understand my responsibility to notify the General Counsel or Assistant General Counsel immediately if any circumstances arise which represent an actual or potential conflict of interest, and that the information provided above is true and correct.
Signature / Date
LEGAL DEPARTMENT USE ONLY
Legal Review: (General Counsel or Designee) / Date:
Action Required:
Yes No / Actions/Comments:
Date Returned:

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