WHISTLEBLOWER REPORT E-FORM
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)







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






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






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.

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





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








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.