Declaration of Conflict of Interest Form

Pursuant to the Code of Business Conduct & Ethics and Conflict of Interest Practice

Employee/Contractor Name: Click here to enter text.

Employee/Contractor JDE Staff ID# (if known): Click here to enter text.

I, Click here to enter text., hereby declare the following actual or potential conflict of interest:

1.	Name of company(s) or individual(s) involved with the actual or potential conflict of interest including Cenovus’s and your relationship with the persons/companies and your role in relation to the persons/companies:

Click here to enter text.

2.	Detailed description of the actual or potential conflict of interest for disclosure:

Click here to enter text.

3.	In agreement with my Cenovus supervisor or Cenovus Representative, we have agreed the following actions are to be taken to mitigate the actual or potential conflict of interest (see the Conflict of Interest Mitigation Examples for guidance):

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The undersigned hereby confirms that the information contained in this Form is true and accurate to the best of his/her knowledge and belief and agrees to the above noted action(s) to be taken to mitigate the actual or potential conflict of interest.

If there is a change to circumstances giving rise to the actual or potential conflict of interest, or any change to the information disclosed in this Form which may require a revision in the mitigation actions outlined, the undersigned acknowledges that a new Form must be prepared and resubmitted.

If you have any questions please contact Enterprise.Compliance@cenovus.com.

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Signature of declaring Employee/Contractor	Date (MM/DD/YY)

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Name and signature of Cenovus Supervisor/Representative	Date (MM/DD/YY)

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Name and signature of direct report of Cenovus Leadership Team	Date (MM/DD/YY)

member, if different from supervisor above

Note: Approval authorities are aligned with the HR Decision Rights Matrix.

Please send the completed form with all required signatures to Enterprise.Compliance@cenovus.com