MBSB Berhad

Complaint Against*

Name*

Staff ID (if applicable)

NRIC No.

Office No.

Mobile No.*

E-mail Address*

Nature of Alleged Misconduct *

Date of incident*

Time of incident*

Place of Alleged Incident*

Name of Person(s) Involved *

Employee's Name

Employee's Address

Designation of the Person(s) Involved

Details of the Alleged Misconduct *

Witness (if any)

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I confirm to the best of my knowledge that all information stated herein is true.

I accept that MBSB has the right to revoke any protection conferred under WPA 2010.

I declare that prior to this disclosure, I have not disclosed the subject matter of the improper conduct or any part thereof to any other person.

I acknowledge to have read MBSB Whistleblowing Policy (the Policy) as published at Whistleblowing Policy – and understand the disclosure stated herein falls within the scope of the MBSB to act upon, as sets out in the Policy.

I agree to maintain confidentiality of all such information that has been disclosed to MBSB, including any part thereof at all times, and shall not for any reasons whatsoever, disclose any information pertaining to this disclosure to any other person after disclosing to the representatives from MBSB.

I understand and accept that any disclosures made to any other person relating to information pertaining to this disclosure may affect my rights and protections under the law, including but not limited to, the Whistleblower Protection Act 2010.

I agree that I may need to be contacted by the named Designated Person of MBSB, or any persons acting on behalf, and shall notify the said Designated Person or his/her representatives of any changes to my contact details as soon as possible.

I agree that matters beyond MBSB purview and investigation powers under relevant law(s) should be forwarded to another more appropriate enforcement agency.

I acknowledge and agree that MBSB reserves the rights to use the information and material provided strictly for the purpose of acting on this disclosure.

For the avoidance of doubt, Personal Data includes all data defined within the Personal Data Protection Act 2010 including all data you had disclosed to MBSB in this Form.

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