Appendix 1.a.

: Declaration Form
DECLARATION OF POTENTIAL OR ACTUAL CONFLICT OF INTEREST

I, the undersigned:
Mr./Mrs/Ms. Nona Innasya ,
Holding the position/duties of Supply Chain Intern ,

Hereby declare:

 That I am currently not in any potential or actual Conflict of Interest situation: 

˅

 Having a consulting activity in parallel of a Job within the Company

 Being a Board Member of any private/public institution or a firm
 Holding a financial interest in a company
 Having a spouse working for a competitor, a supplier or a supervisory
administration
 Holding elective functions (syndicate, work unions, political activity…)
 Holding associative and/or charity responsibilities

 That I have or may have the following Conflict(s) of Interest: 

Brief description of the Conflict of Interest and names of the persons involved in the
matter and/or transmission of the analysis grid below (Appendix 1.b.):

I undertake to immediately inform my managers of any evolution of this Conflict of Interest.

Two original copies signed in Karawang , on Friday, January 06, 2023

Employee’s signature: Nona Innasya

 Appendix 1.b.: Potential or Actual Conflicts of Interest Analysis Grid to be completed by
the employee (the “Declarant”)

Declarant’s Position/Duties

Description of the company or

entity in which the Declarant (i)
holds an economic interest, or (ii)
is/was involved, whether directly or
through a Close Relation:

Description of the operations or

transactions for which the interests
of the Declarant or a Close Relation
conflict with those of Total:

Financial magnitude of the said

operations or transactions in terms
of income and/or profit (please
provide an annual approximate
range for recurring operations):

Potential influence of the employee

on his/her entity’s decisions for the
said operations or transactions:

First and last name of the Declarant: Nona Innasya

Date: 6, January 2023