Position:

Department:

Phone

Is this a group submittal? [ ] Yes [ ] No

If yes,list all members of this group here, and obtain their signatures on the reverse side:

What is the problem? (Please be specific).

What do you propose to improve this situation or problem? Be specific. Attach samples if applicable.

What benefits, savings and implementation costs can be expected from this solution? How did you calculate these savings?

I have read and understand the rules and regulations governing the Suggestion System and agree to be bound by them. I understand that the company has the sole discretion to make an award or not, and that it may use a suggestion without giving an award.

______________________ Date:

Employee