Private and confidential

Declaration Form: Close Personal Relationship

Part 1: Self-Declaration
Name of employee Le Thi Hong Vy

101165815
Staff Code

Grade
Line of Service (LoS) – Audit
Business/ Operating Unit (BU/ OU)

Date of Declaration

Having close personal relationship with:

Name
Staff Code
Grade
LoS – BU/ OU (internal relationship); or
Company – LoS (external relationship)
Nature of personal relationship
Any other relevant information

Name
Staff Code
Grade
LoS – BU/ OU (internal relationship); or
Company – LoS (external relationship)
Nature of personal relationship
Any other relevant information

I confirm that I understand and agree to the terms of related policy.

Signed Name Date

(Signature of employee)

PwC (Vietnam) Limited

29 Le Duan Street, Ben Nghe Ward, District 1, Ho Chi Minh City, Vietnam
T: +848 3823 0796, www.pwc.com/vn
Part 2: LoS Leader & CRM
LoS Leader’s Name

Inputs or Recommendations

LoS Leader’s Signture

Date

LoS CRM’s Name

Inputs

LoS CRM’s Signture

Date

PwC (Vietnam) Limited

29 Le Duan Street, Ben Nghe Ward, District 1, Ho Chi Minh City, Vietnam
T: +848 3823 0796, www.pwc.com/vn