qfcra

REPORTER'S CONTACT INFORMATION

(This section may be left blank if the reporter wishes to remain anonymous, however we encourage you to share your contact details so that we may seek further information or provide feedback during the course of review)

Reference No

Name

Designation

Department

QFC Firm

Contact Number

Email Address

SUBJECT INFORMATION

(The person or persons against whom you are making allegations)

Name

Designation

Department*

QFC Firm*

Contact Number

Email Address

WITNESS INFORMATION

Information on any other person or persons who also witnessed or has information relating to the disclosed reported misconduct

Name

Designation

Department

QFC Firm

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.

1. What firm is the allegation against? *

(Please provide the name of the firm for which the named individual worked at the time of the alleged misconduct) *

2. What misconduct/improper activity occurred? *

3. Who committed the misconduct/improper activity? *

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

5. Where did it happen?*

6. How was the misconduct/improper activity able to occur? Were there controls in place to prevent the activity?

(If there were controls in place, how were they circumvented?)

7. Do you have any documents or evidence that support your report or explain it in more detail which you would be able to provide us?

8. Have you reported this misconduct to your employer/QFC firm? YES or NO

9. If the matter has been reported previously, please confirm when the report was made, to whom it was made, whether it was made in writing and what actions, if any, have been taken?

10. Are there any other parties involved in the alleged misconduct? If so, please provide their names and positions.

11. Let us know if we should be aware of any circumstances during the course of the inquiry. For example, if a certain individual is conflicted and should not be assisting in the inquiry.

12. Any other comments?

Attachments

Declaration

I hereby declare that all information provided herein is true to the best of my knowledge and that all documents provided with this report are true and
accurate copies of the originals.

I understand that the QFC Regulatory Authority will use the information provided in this report to investigate the matters disclosed in the report in
accordance with the applicable rules, policies and procedures.

By pressing the “Submit” button below, I consent to the processing by the QFC Regulatory Authority of my personal data set out in this report.

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