ANNEX II - Application form for the list of members of the management body
Info
🔗 Back to Summary. 🇫🇷 French Version: 2017R1110_FR.II. Back to Summary of LVL1. Link to the PDF. Direct link to EUR-LEX.
Article I – Application form for authorisation to provide data reporting services ⬅️ | ➡️ Article III – Application form for changes to the membership of the management body
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Reference number:
Date:
From:
Name of the applicant:
Address:
Legal Entity Identifier (where applicable): Full Name:
Telephone:
Email:
To:
Member State:
Competent authority:
Address: Address:
Telephone:
Email:
Dear [insert appropriate name]
In accordance with Article 2 of Commission Implementing Regulation (EU) 2017/1110 (1) please find attached the notification relating to the members of the management body.
— Person at the applicant in charge of preparing the application:
Full Name:
Status/position:
Telephone:
Email:
Date:
Signature:
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— List of members of the management body:
Member 1
Full name
Date and place of birth
Personal national identification number or equivalent thereof
Private address:
Contact details (Telephone and email address)
Position
Curriculum vitae attached to application: Yes/No
Professional experience and other relevant experience
Educational qualification and relevant training
Criminal records attached to this application OR self-declaration of good repute and authorisation to the competent authority to make enquiries under Article 4(d) of Commission Delegated Regulation (EU) 2017/571 (2)
Self-declaration of good repute and authorisation to the competent authority to make enquiries under Article 4(e) of Delegated Regulation (EU) 2017/571
Minimum time (approximate) that will be devoted to the performance of the person’s functions within the data reporting services provider
Declaration of any potential conflicts of interest that may exist or arise in performing the duties and how these conflicts are managed
Additional information relevant for the assessment whether the member is of sufficiently good repute, possesses sufficient knowledge, skills and experience and commits sufficient time to perform the duties pursuant to EU of the European Parliament and of the Council (3)
Effective date
[Please set out that information here or provide an explanation of how it will be provided, or make reference to the relevant annexes containing the information]
Member [N]
Full name
Date and place of birth
Personal national identification number or equivalent thereof
Private address:
Contact details (Telephone and email address)
Position
Curriculum vitae attached to application: Yes/No
Professional experience and other relevant experience
Educational qualification and relevant training
Criminal records attached to application OR self-declaration of good repute and authorisation to the competent authority to make enquiries under Article 4(d) of Delegated Regulation (EU) 2017/571
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Self-declaration of good repute and authorisation to the competent authority to make enquiries under Article 4(e) of Commission Delegated Regulation (EU) 2017/571 (2)
Minimum time (approximate) that will be devoted to the performance of the person’s functions within the data reporting services provider
Declaration of any potential conflicts of interest that may exist or arise in performing the duties and how these conflicts are managed
Additional information relevant for the assessment that the member is of sufficiently good repute, possesses sufficient knowledge, skills and experience and commits sufficient time to perform the duties referred to in EU
Effective date
Notes: