A) PERSONAL PARTICULARS OF WHISTLEBLOWER (Optional if a Whistleblower wish to remain anonymous)

1. Name:*

2. I/C No.:*

3. Correspondence Address:*

4. Telephone No.:*

5. Email:*

6. Designation / Occupation:*

7. Employer Name:*

8. Preferred method of communication:*
MailEmailTelephone

B) INFORMATION OF PERSON(S) INVOLVED IN IMPROPER CONDUCT
If more than 1 individual is involved please fill in individual 2 & 3
Individual 1

Name of Person:*

Designation / position of said person in GRSB, Setia City Mall Centre Management Office or SP Setia:*

How do you know this person?*

Individual 2

Name of Person:

Designation / position of said person in GRSB, Setia City Mall Centre Management Office or SP Setia:

How do you know this person?

Individual 3

Name of Person:

Designation / position of said person in GRSB, Setia City Mall Centre Management Office or SP Setia:

How do you know this person?

C) DETAILS OF IMPROPER CONDUCT

Date:*

Time:*

Place:*

Details of Improper Conduct:*

Details of Witnesses (if any):

Please attach additional sheets if necessary. (Optional).

Please submit supporting documents and additional sheets (Optional).

Have you lodged a complaint on this matter to another person / department/ authority before?*
YESNO

D) DECLARATION

I declare that all information provided in this form is true, correct and complete to the best of my knowledge, information and belief.

I hereby agree that the information provided herein to be used and processed for investigation purposes and further agree that the information provided herein may be forwarded to another department/ authority/ enforcement agency for purposes of investigation.

I accept the following conditions.*