Whistleblowing Form – Lemonilo

Whistleblowing Report Form

Reports may be submitted with the whistleblower’s personal information or anonymously. We assure the strict confidentiality of any personal data provided.

Whistleblower Disclosure *Do you wish to disclose your identity?AnonymousFull

Whistleblower Name *Reporter/Whistleblower Name

Email AddressWhistleblower Email Address

Phone Number *Whistleblower Phone Number

Whistleblower Relationship *RelationshipEmployeeVendorCustomerOther

Reported Party Name *Please identify the person involved/The Party Being Reported

Reported Party Business Unit/CompanyPlease identify the person involved Business Unit/Company

Incident Type *Incident TypeFraudConflict of InterestCode of ConductRegulatory Breach

Incident Location *Location where the incident occurred

Incident Time *Time where the incident occurred

Incident Details *Details

Incident RepetitionDo you think this problem occurred before?

Witness *Is there any witness in the incident?

Incident Escalation to Appropriate Channel or Individual *Has the issue been reported to the appropriate channels or individuals? If yes, to whom?YesNo

Explain

Incident Escalation to Local Authorities *Has the problem been reported to local authorities?YesNo

Threat (If any) *Did you get any threats? If yes, please elaborate.YesNo

Explain

EvidenceMaximum 20MB (Photo, Video, Audio, Document, Compressed File)

Drag and Drop (or) Choose Files

*Please tick the box *

I acknowledge that the report and all information contained therein shall be provided to Lemonilo to be stored and used for the purpose of handling complaints and may be disclosed to law enforcement agencies or regulatory authorities, in accordance with the requirements necessary to comply with applicable laws, regulations and provisions.