Whistle-Blower Disclosure Form - ESX

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Whistle-Blower Disclosure Form

1. Provide My Personal Details

Yes No

2. Reporter Type

External Reporter Employees of ESX

3. Reporter’s Contact Information

Full Name

Job Title

Department/Team

Email

Phone/Mobile No

4. Case Topic/Reportable Breaches (choose at least one)

Failure to comply with any legal obligations or regulatory requirements. Criminal offences, breach of civil law and miscarriage of justice. Malpractice, impropriety or fraud relating to internal controls, accounting, auditing and financial matters. Breach of rules, policies or internal controls of the Exchange. Danger to the health and safety of any individual within the Exchange’s facilities. Damage to the environment. Violation of rules of conduct applicable within ESX. The use of deception to obtain an unjust or illegal financial advantage, by an individual. Improper conduct, unprofessionalism or unethical behaviour likely to prejudice the reputation or standing of ESX. Bribery or corruption. Deliberate concealment of any of the above, among others. Others

Please specify

5. Case Details (Please provide as much details as possible)

5.1 What misconduct/improper activity occurred?

5.2 Information about the Person Engaged in the reportable breaches (misconduct/improper activity)

Full Name

Department/Team

Phone/Mobile No.

Email

5.3 Information about the Person Engaged in the reportable breaches (misconduct/improper activity)

Date of occurrence

Time of occurrence

Place/City of occurrence

5.4 How long do you think this problem has been going on?

5.5 How did you become aware of this violation?

5.6 Is there any evidence or any other details or information which could assist us in the investigation?

Yes No

If any, please attach

5.7 Are there any other parties involved other than the suspect stated above?

Yes No

If Yes, please mention his/her full name and position

5.8 Do you suspect or know that a supervisor or management is involved?

Yes No

If Yes, please mention his/her full name and position:

Name

Position

5.9 Is Senior Management aware of this problem?

Yes No Do Not Know Do not want to disclose

5.10 Please identify any persons who have attempted to conceal this problem and the steps they took to conceal it.

5.11 Any other comments?

You can also provide tips through a dedicated email at whistleblow@esx.et at or via postal mail that should be marked as ‘personal, private and confidential’ and address to: Risk and Compliance Team, Ethiopian Securities Exchange, P.O.Box 12101, Addis Ababa, Ethiopia.

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