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��� Building Efficiency (BE) North America <br /> �'�i"'��' Regional Supplier Record Add/Change Form <br /> Requester Manager To be answered by the REQUESTER and MANAGER: <br /> ❑Yes ❑Yes Is the supplier owned by or managed by a friend or a relative of yours or are you aware of this <br /> � No � No relationship with anyone at your branch or within your department? <br /> ❑Yes ❑ Yes Are you aware of any JCI employee with a financial stake(ownership or investment) in this <br /> � No � No company, or have knowledge of any other conflict of interest? <br /> �Yes �Yes Do you understand that providing false information regarding this supplier or your relationship to <br /> ❑ No ❑ No this supplier may result in disciplinary action from Johnson Controls? <br /> �Yes �Yes Su lier Due Dili ence erformed and a <br /> ❑ No ❑ No pp 9 P pproved per BOS Policy#13-18.102.BEHQ <br /> REQUESTER name(print): Tracey DeVille REQUESTER signature: <br /> MANAGER name(print): Kara Tuttamore MANAGER signature: <br /> Fill out by Requester <br /> Supplier Status ❑Active/Approved ❑ Do Not Use/Do Not Pa <br /> y ❑ Retired/Inactive <br /> Requested: <br /> All Add/Change requests are subject to supplier background checks. <br /> �/,�ndvr�1Aas�mr.AdnNnistralcN ��� �y,�s [�No Ver�clor Ma�ter Ac�miN�k�r <br /> �1�ip��91"�Wt: k� (�): <br /> Form#13-51.600.BEHQ Page 2 of 4 Effective Date 15-June-2009 <br /> This document contains trade secrets and proprietary information of Johnson Controls,Inc. Disclosure of this publication is absolutely prohibited without the <br /> ex ress written ermission of Johnson Controls,lnc. 0 2009 Johnson Controls,Inc. All ri ts reserved. <br />