Citra Nusa Holdings Berhad

e-Form

Whistle Blowing e-Form

- Please fill all the fields marked with (*). In the event the information is not available at the time the case is lodged, please type ‘Not Available’ in the field.

- In order for us to conduct a thorough investigation, please provide information as accurate as possible.

- Anonymous complaint will not be entertained.

Personal Particulars of Whistleblower

Name*:

IC No / Staff No*:

Corresponding Address*:

Telephone No (Home):

Telephone No (Office):

Telephone No (Mobile)*:

Email Address*:

Designation / Occupation* :

Preferred Communication Method*:
Mail
Email
Telephone

Information of CNI Employee(s) Involved in Improper Conduct

Individual 1
Name of CNI employee*:

Designation of CNI employee*:

Individual 2
Name of CNI employee*:

Designation of CNI employee*:

Individual 3
Name of CNI employee*:

Designation of CNI employee*:

Please tick the box if the alleged wrongdoer is the Audit Committee Chairman

Details of Improper Conduct

Date of incident*:

Time of incident*: (e.g: 03:00 PM)

Location of incident*:

Details of Improper Conduct*:

Details of Witnesses (if any):

Any monetary value involved?*: Yes No

Supporting Documents (if any):

Have you lodged a complaint on this matter to another person / department / authority before?: Yes No

Policy

e-Form

Personal Particulars of Whistleblower

Information of CNI Employee(s) Involved in Improper Conduct

Details of Improper Conduct