| Step 1 of 3

HSBC Mauritius - Raise Your Concern Form

We recommend that you do not provide any confidential information such as your account number, credit card number etc.

Kindly note that all fields with * are mandatory.

Title
Are you an existing customer

* I confirm and agree that my consent granted herein are solely in relation to the referral activity requested, for one-time use only and do not supersede or replace any other consent which I may have previously provided to HSBC Group in respect of my personal data, and are additional to any rights which HSBC Group may have at law to collect, use or disclose my personal data

By providing the information set out above and submitting this form, I/we consent that the Information, the Reports and their form, format, mode or method of compilation, selection, configuration, presentation and expression (collectively 'Confidential Information') are trade secrets and confidential and proprietary property of the Bank and the respective Information Providers.

| Step 2 of 3

HSBC Mauritius - Raise Your Concern Form

Please confirm and submit your information.

Title

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First name

{{firstName}}

Last name

{{lastName}}

Town/Village

{{city}}

ID number

{{idNumber}}

Phone number

{{phoneNumber}}

Email address

{{email}}

Are you an existing customer

{{existingCustomer}}

Preferred contact time

{{contactTime}}

Product or Service related

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Comment

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| Step 3 of 3

HSBC Mauritius - Raise Your Concern Form

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