Compliance Supplier Qualification Questionnaire

Failure to complete this Questionnaire in its entirety may cause Chevron Nigeria Ltd. to discontinue the qualification process with Supplier. Filling out Questionnaire in full does not obligate Chevron Nigeria Ltd. to include Supplier on any Bidders List or
other sourcing event. Supplier must update the information contained in this Questionnaire as changes occur.

Do not respond "N/A" or "Not Applicable" to any question without explaining why question is not applicable to you.
If space provided in Questionnaire is insufficient to fully respond to questions asked, we encourage you to continue your responses on additional sheets of paper.

Supplier's responses will be treated as confidential and Chevron Nigeria Ltd. will use responses internally for purpose of qualifying Supplier to potentially perform services or deliver goods. No information revealed in this Questionnaire will be made
available to any third party unless required by applicable law, court order, decree, regulation or rule, or where failure to disclose could reasonably result in sanctions against Chevron Nigeria Ltd.

Chevron Nigeria Ltd. may verify the validity of the information as it deems necessary and Supplier shall cooperate with Chevron Nigeria Ltd. in this regard.

1 SUPPLIER'S BASIC INFORMATION

Full Legal Entity Name of Company or Individual that will be Party to particular contract, in some cases this is a local affiliate. ("SUPPLIER")
a. ADAK-RAPH NIG LTD
Provide copy of your 'Certificate of Registration of Business Name' ( Nigeria Specific CAC/BN/A2)

Local Business Address.

b. Provide copy of your 'Notice of Change in Registrated Address' or CAC 3 'Notice of Situation/Change of Registered Address'' 1, OMOMOWO QUARTERS, AWOYE, ONDO STATE.
(Nigeria Specific CAC/BN/B3 or CAC 3)

c. Contact Name OMOMOWO ADEKUNLE RAPHAEL

d. Telephone Number 8065533004

e. Fax Number

f. E-mail Address adakraph@yahoo.com

g. Form of Business (ex.,Private Limited Company, Public Limited company, corporation, partnership, etc.) PRIVATE LIABILITY COMPANY

h. Place of Registration CORPORATE AFFAIRS COMMISSION, NIGERIA

i. List Supplier's previous names for the past five (5) years. ADAK-RAPH NIG LTD

j. Have you entered into a contract with Chevron Nigeria Ltd. in past five (5) years?
NO
If yes, provide details including type of service or product, dates, location, and contact information.

k. Provide Suppliers Registration, Licences and other requirements necessary to perform services or deliver goods.
DEPARTMENT OF PETROLEUM RESOURCES CERTIFICATE (DPR)
If not provided, explain.

2 BUSINESS INFORMATION

Have you engaged with an entity to fulfill local content or other requirements necessary to do business in the country where services will be
a performed and/or where the goods will be used? NA
If yes, provide detailed information. (This does not include subcontractors).

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To best of your knowledge are there any known personal relationships between personnel of Supplier or its Affiliates and any Chevron
b personnel? NO
If yes, provide detailed information.

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BENEFICIAL OWNERS AND MANAGEMENT OF CONTRACTING ENTITY
"Beneficial Owners" as used in this Questionnaire are defined as those who own or control five percent (5%) or more of beneficial interest.

Is this company a Publically Held Company?

a. If Supplier is a publicly held entity (e.g. Public Company), attach a copy of your most recent public filing or equivalent NO
documentation showing Supplier's Beneficial Owners.

If Supplier is not a publicly held entity (e.g. Public Company), list Beneficial Owners, their individual percentage ownership and their place of Registration.
Provide copy of forms 'Particulars of Directors or any Change Therein' and 'Statement of Share Capital and Return Allotment of Shares' ( Nigeria Specific CAC 7 and CAC 2)

Country of Registration or
Owners Names Home Address Percentage/Ownership
Nationality

OMOMOWO ADEKUNLE RAPHAEL 1, OMOMOWO QUARTERS, AWOYE, ONDO STATE. NIGERIAN 40%
b.
OMOMOWO ALABA GODWIN 1, OMOMOWO QUARTERS, AWOYE, ONDO STATE. NIGERIAN 15%
OMOMOWO IMOLE 108, OMONIRA STREET, IGBOKODA, ONDO STATE. NIGERIAN 15%
SHEDRACK BLESSING 1, OMOMOWO QUARTERS, AWOYE, ONDO STATE. NIGERIAN 15%

SHEDRACK MERCY 108, OMONIRA STREET, IGBOKODA, ONDO STATE. NIGERIAN 15%

c. List names of all Officers and Directors of Supplier.

Names Home Address Company Position/Title

OMOMOWO ADEKUNLE RAPHAEL 1, OMOMOWO QUARTERS, AWOYE, ONDO STATE. ADAK-RAPH NIG LTD MANAGING DIRECTOR

SHEDRACK BLESSING 1, OMOMOWO QUARTERS, AWOYE, ONDO STATE. ADAK-RAPH NIG LTD DIRECTOR

OMOMOWO ALABA GODWIN 1, OMOMOWO QUARTERS, AWOYE, ONDO STATE. ADAK-RAPH NIG LTD DIRECTOR

OMOMOWO IMOLE 108, OMONIRA STREET, IGBOKODA, ONDO STATE. ADAK-RAPH NIG LTD DIRECTOR

SHEDRACK MERCY 108, OMONIRA STREET, IGBOKODA, ONDO STATE. ADAK-RAPH NIG LTD DIRECTOR

List names and addresses of any other individual, company or entity if they will receive any portion of compensation as a result of participating in any type of partnership, joint venture or alliance with Supplier in proposed
contract.

Percentage/Amount
Names Home Address Affiliation with Supplier Position/Title
of Compensation

d.

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4 RELATIONSHIPS WITH GOVERNMENTS AND PUBLIC INTERNATIONAL ORGANIZATIONS
Is any person identified in response to Section 3 above:
Yes/No

(i) Officials/Prior Officials? NO

a. (ii) Relatives of Officials/Prior Officials? NO

(iii) Involved in any business relationship with any Official/Prior Official or family member of an Official/Prior Official? NO

(iv) Individuals or employees operating with official government-like authority? (e.g., traditional rulers, tribal or community leaders) NO

(v) An agent or intermediary acting in an official capacity or on behalf of any of the above? NO

"Official" as used in this Questionnaire means any officer, employee or other person acting in an official capacity for any government or any department, agency or instrumentality of any government or for a Public International Organization (which means an international
organization formed by states, governments or other public international organizations, whatever the form of organization and scope of competence); can include an individual or organization operating with functional authority typical of a government officer or entity (e.g.,
traditional rulers or tribal or community leaders).

Officials are further defined as follows:

• Any officer, employee, or other person acting in an official capacity for a foreign (non-U.S.) government or any department, agency, or instrumentality thereof,
• Any business that is owned or controlled by a government,
• Any individual or employee of an organization operating with official government-like authority (e.g., traditional rulers or tribal or community leaders),
• Any officers, employees, or other personnel acting in an official capacity of a public international organization (e.g.United Nations, World Bank, & International Committee of Red Cross),
• Political parties, party officials, and candidates for office,
• Any agent or intermediary acting in an official capacity or on behalf of any of the above.

If answer to (i) is YES, provide details

Dates of Service
Name of person who is an Official/Prior Official Title and Government Relationship
(current or past)

b.

If answer to (ii) is YES, provide details

Name of person Dates of Service

Relationship to Official Title and Government Relationship
related to Official/Prior Official (current or past)

NA

c.

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If answer to (iii), (iv), or (v) is YES, provide details

Name of person with Business Relationship Type of Business Relationship Title and Government Relationship Dates of Relationship

d. NA

5 LITIGATION HISTORY Yes/No

Has Supplier or its Affiliates been cited or investigated by a government agency for non-compliance with any governmental rule or regulation
a. of a material nature in past five (5) years? If yes, provide detailed information. NO

Has Supplier adopted a Human Rights Policy? If yes, provide copy of such Policy with your response to this Questionnaire.
b. YES

Has Supplier or its Affiliates been found, by a lawfully authorized judicial or other government body, to have violated or settled without a finding
of violation of any applicable child labor laws?
c. NO
If yes, provide information related to said violation as well as any information relevant to all remedial efforts undertaken to correct underlying
conduct.

6 ADDITIONAL INFORMATION Yes/No Comments/Information

a. Is there any other information that Supplier wishes to disclose about itself that may be relevant to Chevron Nigeria Ltd. If Yes provide details NA

Will Supplier require partial or full payments of invoices to be paid in currencies other than Naira?
b. If so, provide details NA

Will Supplier require payments in any currency to be sent outside of Nigeria.

c. NA
If so, provide details

Undersigned is authorized to certify on behalf of Supplier and does hereby certify that all information in this Questionnaire and its attachments are true and
correct and that no important or relevant information has been omitted.

Signature:

Name: OMOMOWO ADEKUNLE RAPHAEL Company ADAK-RAPH NIG LTD

Title: MANAGING DIRECTOR Date: 18 June, 2019.

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