E&P MOZAMBIQUE AREA 1, LIMITADA

POTENTIAL EMPLOYEES OR CONTRACTOR PERSONNEL

QUESTIONNAIRE, AUTHORIZATION, AND CERTIFICATION
This questionnaire, authorization, and certification is used to collect information from prospective employees or
contractor personnel for Total E&P Mozambique Área 1, Lda., its subsidiaries or its affiliates ("Company") and is
used to help Total comply with applicable laws such as the anticorruption laws of Mozambique, the United States
Foreign Corrupt Practices Act ("FCPA"), and the U.K. Bribery Act (together “Anti-corruption Laws”).

Please answer all questions accurately and completely. Attach additional pages if needed.

1. Information about you

Full Legal Name
All address(es)
used by you in the
last 5 years
Telephone
Email
Passport Type of ID: ____________________
(preferred) or ID Number: ____________________
other government- Issued by: ____________________
issued Expiry date: ____________________
identification Copy attached? Yes ____ No _____

2. I have attached a copy of my resume or C.V. which includes information about my education and business
experience. Yes ____ No ____

3. Personal references. List the names and contact information for persons you agree Company may contact
regarding your personal, professional, and business reputation and abilities.
Name Address Phone Email

4. Do you have friends, family, or close associates who work, or have worked, for Company or any of its affiliates?
Yes ___ No ___

If Yes, list them here:

The person’s name Who they Their relationship Their phone Their email address
worked for to you number

5. Do you own or control, in whole or in part, any entity that may do business, or may have done business, with or
for Company? Yes ___ No ___
If yes, list them here:

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[We understand that you do not know all of Company’s vendors or suppliers. But if you own or control, in
whole or in part, any entity that you know or believe is doing, or has done, business with Company, we
expect you to list it here]
Full Name of Entity Describe the nature of your ownership or right to control

6. Public Officials
For these questions “Public Official” means:
 an employee of a government authority (this includes any national, regional or local government, any
ministry, national directorates, national institutes, provincial government, provincial directorates or
department thereof); or
 any person exercising the executive, legislative, judicial, regulatory, or administrative functions of any
government (including any independent regulator) or
 an employee of any other governmental entity, instrumentality, agency, authority, court, or company,
or
 an employee of any other entity, committee or commission under the direct or indirect control of a
government, or
 an official of any political party or a candidate for political office, or
 an employee of any government-owned or controlled commercial enterprise (including any national oil
company), or public international organization (such as the United Nations, the World Bank, the
International Bank for Reconstruction & Development, the European Bank for Reconstruction and
Development, etc.).

(a) Are you now, or have you ever been, a "Public Official"? Yes ___ No ___
If you answered yes, provide details including name and address of the entity in which you worked as well as
position held and time:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

(b) Is a member of your family “Public Official”? Yes ___ No ___

If you answered yes, provide details including name and address of the person, relationship with the candidate as
well as position held and time:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

(c) Are you a close social or business associate of a “Public Official”? Yes ___ No ___
If you answered yes, provide details including name and address of the person, relationship with the candidate as
well as position held and time:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

7. Are you familiar with the prohibitions against bribery in Anti-corruption Laws?
Yes ___ No ___

8. Have you ever been accused of violating the Anti-corruption Laws, or engaging in any practice involving bribery
or the making of an improper payment to a Public Official? Yes ___ No ___
If you answered yes, provide details: ______________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

9. Have you ever been charged with a criminal offense or violation of the law (in any country)? Yes ___ No ___

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If you answered yes, provide details: ______________________________________________________

____________________________________________________________________________________
____________________________________________________________________________________

Background Screening and Consumer Reports. In connection with your application, Company (directly or by a third
party) may make inquiries and solicit information about you from private and public record sources including the
preparation of a consumer report on you by a consumer reporting agency or similar organization (the “Agency”).
The information gathered will include information bearing on your character, general reputation, personal
characteristics, and mode of living. The types of information may include, but is not limited to, background
references, credit history, criminal history, education verification, civil court and driving records, and verification of
prior employment. By signing below, you agree to release and hold harmless, to the maximum extent allowed by
law, the Company and all parties involved with gathering or providing such background or consumer report
information from any liability whatsoever for any damages whether at law or in equity that may result from
gathering or providing such information.

AUTHORIZATION AND CERTIFICATION

By my signature below, I consent to the release to the Company of background screening and consumer report
information described above. I understand that if the Company retains my services as an employee or as a contract
employee, the Company may rely on this authorization to obtain additional information or reports on me without
asking for my consent again to the extent permitted by applicable law. I also authorize all of the following to
disclose to the Agency and its agents all information about or concerning me: my past or present employers;
learning institutions, including colleges and universities; law enforcement and all other federal, state and local
agencies; federal, state and local courts; credit bureaus; drug and alcohol testing facilities; motor vehicle records
agencies; all other private and public sector repositories of information; and any other person, organization, or
agency with any information about or concerning me. The information that can be disclosed to the Agency and its
agents includes, but is not limited to, information concerning my employment and earnings history, credit history,
education, motor vehicle history, criminal history, military service, professional credentials and licenses.

Furthermore, by signing below, I certify that:

(a) I have carefully read, and I understand, this Authorization and Certification;
(b) I have full legal capacity to complete this Questionnaire, Authorization, and Certification;
(c) the name shown below is my true and complete legal name;
(d) the answers to this Questionnaire are true, correct, and complete to the best of my knowledge;
(e) I understand that any deliberate falsification, misrepresentations or omissions of fact by me may be grounds
for the immediate termination of any subsequent employment or contract with the Company; and
(f) I covenant and agree that I will not violate the Anti-corruption Laws, or any other applicable anticorruption
law during the course of any work I may do for the Company.
(g) I understand that filling out this Questionnaire, Authorization, and Certification is part of the process I must
follow to apply for a position with AMA1 and it is not an offer or guarantee of employment.

Date: ___________________________________________

Complete legal name: _____________________________

Signature: _____________________________

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TOTAL Classification: Restricted Distribution
TOTAL - All rights reserved