WHISLEBLOWER FORM – MIBEXCHANGE

MIBEXTECHNOLOGIES s.r.o. shall treat all protected disclosuers in a confidential and sensitive manner. This Whistleblower Form allows you the opportunity to provide your name and contact information as this information may assist us in investigating your concern. Should you not wish to provide your name, reported incidents will still be accepted and investigated , as approriate.

Instructions:

Please provide as much detail as possible. If you wish to remain anonymous, do not include your relationship to persons identified in your report or location relative to persons or incidents in your report. If you intend to print and mail this form, please attach additional pages if you need more room to complete the form.

1. Please provide details with respect to the location of the incident.

2. Please describe the nature of your concern regarding financial and/or operational matters. Include sufficient information for an independent person to understand the concern and to enable further investigation.

3. Please state the full name (s) and title (s) of individuals whom you suspect of wrongdoing.

4. How many times has this incident taken place (if applicable)?

5. How long has this incident been taking place (if applicable)?

6. Would you be willing to provide your name and contact information? If yes, please provide your name, email address and telephone number. (Please note this is optional).

7. Would you like to arrange a meeting/telephon call with an Investigating Officer to discuss the matter? (Please note that this option is only open to individuals who chose to provide their name).