REPORTING FORM: WHISTLE-BLOWING COMPLAINT/REPORT

REPORTING FORM FOR EMBEZZLEMENT

Please provide information as follows:
( * Required fields )

1
*Branch / Division of Stopanska Banka AD - Skopje:
 
 
2  
*Location where the incident occurred:
 
Physical address, Branch or Sub-branch of Stopanska Banka AD - Skopje
 
3  
City:
 
4  
* Are you an employee of Stopanska Banka AD - Skopje?
 
 
5  
* Do you wish to remain anonymous when submitting this Reporting Form?
 
 
6  
If you wish Stopanska Banka AD - Skopje to know your identity, please complete the following designated fields:
Your Name:  
Your Surname:  
Your Phone Number:  
Your E-mail address:  
Your postal address:  
Please enter the best time and manner for communication with you:  
7  
What do you estimate the monetary value of this matter, subject to your reporting to be? (select the most appropriate option)
 





Enter the approximate amount

8  
*Please identify the person(s) engaged in this incident:
Examples:
Petko Petkov, Manager of Division for ��.
Unknown, Unknown, Controller
Name Surname Position
     
     
     
 
 
 
9  
Are you familiar with possible reasons which influenced the person for conducting this incident?
 

If the answer is Yes, please state the reasons.  
Example: Financial problems ����
10

Do you suspect or know that other persons are familiar with this incident?



If the answer is Yes, please state the persons. Example: Petko Petkov, Teller

Note: Any persons mentioned here will be restricted from access to this reported information. 
11  
What is the general nature of this incident?
 
This should be a general description only, you will be asked for specifics later
Examples:
Misstatement of revenues or expenses;
Wrongful transactions;
Misapplication of accounting principles and rules.
12  
Where did this incident or violation occur?
 
We recognize that this incident may not have occurred in a particular location. However, if this incident was observed in some documentation or business transactions, please indicate this accordingly.
13  
Please provide the specific or approximate time this incident occurred:
 
Examples:
Monday, 4 December 2006; or
One week ago; or
Approximately a month ago.
14  
*How long do you think this problem has been going on?
 






 
15  
*How did you become aware of this violation?
 





 
If the answer is Other, please state how?  
16

 Did you inform certain employee of Stopanska Banka AD � Skopje regarding said incident ?

 
If the answer is Yes, please state the persons informed.  
Please state the persons (Name and Surname) and their position. Note: Any persons mentioned here will be restricted from access to this reported information.
Example: Petko Petkov, Manager of .....
17

  If you have informed certain employee of Stopanska Banka AD � Skopje regarding said incident, please state when and how did you inform him/her?

 
Examples:
On 8.01.2007, one week after the incident;
Through regular mail, through e-mail;
Informed verbally � do not have written evidence.
18
If you have informed certain employee of Stopanska Banka AD � Skopje regarding said incident, please state the measures undertaken to resolve the issue:
 
Examples:
Ignored it;
Changed documents;
Said it was not a problem;
Said they would look into.
19
* Please provide all details regarding the incident you are reporting, including the locations of witnesses and any other information that could be valuable in the evaluation and ultimate resolution of this issue.

Please take your time and provide as much detail as possible, but exercise care to not provide details that may reveal your identity unless you wish to do so. The detailed description of the incident is of large importance and will enable complete investigation of the matter, especially in cases where you are the only person aware of this situation.  
 

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