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Date of filing

Name

Position

Place of work / organizational unit

E-mail addressl *

* Necessary to send confirmation of receipt of the application.

Date of occurrence of irregularity/violation, date of receipt of information:

Indication of which internal regulations, laws or standards the report concerns:

Description of the subject of the violation/incident:

Indication of evidence relevant to the case:

Nature of irregularities
Failure to fulfill obligationsAbuse of authorityViolation of regulationsOther

Potential witnesses to irregularities:

Attachments

I declare that by submitting this application:

1. I am acting in good faith, not for the purpose of gaining profit,

2. I have a reasonable belief that the allegations contained in the disclosed information are true,

3. The disclosed information is consistent with the state of my knowledge and I disclose all known facts and circumstances concerning the subject of the notification,

4. I am familiar with the RZW Regulations