Your Information (You, the person completing the form)

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Your Name & Contact Information	♦ First Name ♦ Last Name ♦ Job Title ♦ Employee ID ♦ Phone Number Include the area code, extension, and/or dialing codes if applicable. ♦ Email (Format: username@domain.com) ♦ Are you a member of the Legal Team? Yes No (Select One) ♦ What is the name of your manager?

Employee (On whose behalf this disclosure is being made)

On Behalf Of	♦ Is this disclosure being made on behalf of another employee? Yes No (Select One)

Employee Name & Contact Information	♦ First Name ♦ Last Name ♦ Job Title ♦ Employee ID ♦ Phone Number Include the area code, extension, and/or dialing codes if applicable. ♦ Email (Format: username@domain.com)

Location

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Location

Conflict of Interest

Type of Conflict	Type of existing or potential Conflict of Interest. (Select One) Potential Conflict of Interest Involving Outside or Secondary Employment Work, or any other activities, performed outside the Company for the benefit of yourself or any other person, whether or not you are paid, which could have a negative impact on the Company's reputation, or which could interfere (or has the appearance of interfering) with your ability to act in the best interests of the Company or with your Company time commitments. Potential Conflict of Interest Involving an Immediate Family Member Having an Immediate Family Member that is employed by the Company, a supplier, customer or competitor. Immediate Family Member is defined as your spouse, parents, children, siblings, mothers and fathers-in-law, sons and daughters-in-law, brothers and sisters-in-law, step-children and step-parents. Potential Conflict of Interest Involving Investments Outside of the Company Making or holding investments in competitors or in companies with whom the Company does business if such investments have the effect or appearance of influencing your business judgment and duty to the Company. This also includes investments or loans to or from suppliers, customers or competitors. Potential Conflict of Interest Involving Gifts or Entertainment. The receipt or giving of gifts or gratuities (for example, from/to a supplier or dealer) that may be perceived as a conflict of interest. Potential Conflict of Interest Involving Board Participation Outside board participation that is not part of your Harley-Davidson job responsibilities. Other Outside Activities Participation on a motorcycle racing team; outside speaking engagements and appearances, etc. that are not part of your Harley-Davidson job responsibilities.

Type of Conflict

Type of existing or potential Conflict of Interest.

(Select One)

Potential Conflict of Interest Involving Outside or Secondary Employment

Work, or any other activities, performed outside the Company for the benefit of yourself or any other person, whether or not you are paid, which could have a negative impact on the Company's reputation, or which could interfere (or has the appearance of interfering) with your ability to act in the best interests of the Company or with your Company time commitments.

Potential Conflict of Interest Involving an Immediate Family Member

Having an Immediate Family Member that is employed by the Company, a supplier, customer or competitor. Immediate Family Member is defined as your spouse, parents, children, siblings, mothers and fathers-in-law, sons and daughters-in-law, brothers and sisters-in-law, step-children and step-parents.

Potential Conflict of Interest Involving Investments Outside of the Company

Making or holding investments in competitors or in companies with whom the Company does business if such investments have the effect or appearance of influencing your business judgment and duty to the Company. This also includes investments or loans to or from suppliers, customers or competitors.

Potential Conflict of Interest Involving Gifts or Entertainment.

The receipt or giving of gifts or gratuities (for example, from/to a supplier or dealer) that may be perceived as a conflict of interest.

Potential Conflict of Interest Involving Board Participation

Outside board participation that is not part of your Harley-Davidson job responsibilities.

Other Outside Activities

Participation on a motorcycle racing team; outside speaking engagements and appearances, etc. that are not part of your Harley-Davidson job responsibilities.

Outside or Secondary Employment	Please provide the following information: ♦ Describe current H-D job responsibilities: ♦ List the job title and description of secondary job responsibilities: ♦ How many hours per week do you plan to work at the secondary employer? ♦ Will the secondary employer offer wages and/or other compensation or non-monetary benefits (development opportunity, sponsorships, discounts, free product, etc.)? Yes No (Select One) ♦ Describe: ♦ List the contact person/telephone # of secondary employer who can confirm, the above information and/or provide Harley-Davidson with additional information if required:

Outside or Secondary Employment

Please provide the following information:

♦

Describe current H-D job responsibilities:

♦

List the job title and description of secondary job responsibilities:

♦

How many hours per week do you plan to work at the secondary employer?

♦

Will the secondary employer offer wages and/or other compensation or non-monetary benefits (development opportunity, sponsorships, discounts, free product, etc.)?

Yes No

(Select One)

♦

Describe:

♦

List the contact person/telephone # of secondary employer who can confirm, the above information and/or provide Harley-Davidson with additional information if required:

Previously Reported	♦ Has this been reported previously? Yes No (Select One) ♦ Approximate date of your previous disclosure. (Format: mm/dd/yyyy)

Details	♦ Provide as much detail as possible regarding this existing or potential Conflict of Interest.

Acknowledgement

Acknowledgement	♦ Acknowledgement By checking this box, I acknowledge that I understand and agree that the information I have provided above is true and accurate. I also reconfirm my Employee Commitment and agree that I have a duty of confidentiality to Harley-Davidson Motor Company.

Acknowledgement	♦ Acknowledgement By checking this box, I acknowledge that I understand and agree that the information I have provided above is true and accurate. I also understand and agree that I authorize Harley-Davidson to contact the Secondary Employer, if deemed necessary, to confirm the above information and/or to obtain additional information regarding my secondary employment. I confirm that I have certified as to my Employee Commitment and understand and agree that I have a duty of confidentiality to Harley-Davidson Motor Company and that I will not disclose or use any confidential or proprietary information I have or know as a result of my employment with Harley-Davidson in connection with any of my work for the Secondary Employer. I understand and agree that my employment at the Secondary Employer is wholly separate from my employment by Harley-Davidson. Any and all benefits I am entitled to as a result of my employment by Harley-Davidson are not applicable to my secondary employment. For example, if I become injured while working at my secondary employment, I understand and agree that such injury would not be covered by workers’ compensation coverage provided by Harley-Davidson. I understand and agree that, if Harley-Davidson agrees to allow me to accept this secondary employment, Harley-Davidson retains the right to unilaterally revoke its agreement for any reason.

Acknowledgement

♦

Acknowledgement

By checking this box, I acknowledge that I understand and agree that the information I have provided above is true and accurate.

I also understand and agree that I authorize Harley-Davidson to contact the Secondary Employer, if deemed necessary, to confirm the above information and/or to obtain additional information regarding my secondary employment.

I confirm that I have certified as to my Employee Commitment and understand and agree that I have a duty of confidentiality to Harley-Davidson Motor Company and that I will not disclose or use any confidential or proprietary information I have or know as a result of my employment with Harley-Davidson in connection with any of my work for the Secondary Employer.

I understand and agree that my employment at the Secondary Employer is wholly separate from my employment by Harley-Davidson. Any and all benefits I am entitled to as a result of my employment by Harley-Davidson are not applicable to my secondary employment. For example, if I become injured while working at my secondary employment, I understand and agree that such injury would not be covered by workers’ compensation coverage provided by Harley-Davidson.

I understand and agree that, if Harley-Davidson agrees to allow me to accept this secondary employment, Harley-Davidson retains the right to unilaterally revoke its agreement for any reason.

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Conflict of Interest Disclosure Report Form

Statement of Purpose

Your Information (You, the person completing the form)

Employee (On whose behalf this disclosure is being made)

Location

Conflict of Interest

Please provide the following information:

Acknowledgement

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