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Please provide the following details for any suspected serious misconduct or any breach or suspected breach of law or regulation that may adversely impact the Company, and submit the form directly to any member of the Whistleblowing Committee. Please be aware that you may be called upon, to assist in the investigation, if required.

REPORTER’S CONTACT INFORMATION

(This section may be left blank if the reporter wishes to remain anonymous)

NAME (OPTIONAL)

DESIGNATION

DEPARTMENT/FUNCTION

CONTACT NUMBER

EMAIL ADDRESS *

SUSPECT’S INFORMATION

NAME *

DESIGNATION (OPTIONAL)

DEPARTMENT/FUNCTION *

CONTACT NUMBER

EMAIL ADDRESS

No file chosen

WITNESSES’S INFORMATION (if any)

NAME

DESIGNATION (OPTIONAL)

DEPARTMENT/FUNCTION

CONTACT NUMBER

EMAIL ADDRESS

COMPLAINT:

Briefly describe the misconduct / improper activity and how you know about it. Specify what, who, when, where and how. If there is more than one allegation, number each allegation and use as many pages as necessary.

1. What misconduct / improper activity occurred? *

2. Who committed the misconduct / improper activity? *

3. When did it happen and when did you notice it? *

4. Where did it happen? *

5. Is there any evidence that you could provide us?

6. Are there any other parties involved other than the suspect stated above?

7. Do you have any other details or information which would assist us in the investigation?

8. Attachment of evidence:

Date:

Whistleblower Report Form

REPORTER’S CONTACT INFORMATION

SUSPECT’S INFORMATION

WITNESSES’S INFORMATION (if any)

COMPLAINT:

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