ANNEX III - Application form for changes to the membership of the management body
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Article II – Application form for the list of members of the management body ⬅️ | ➡️ Retour au sommaire
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Reference number:
Date:
From:
Name of the data reporting services provider:
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 4 of the Commission Implementing Regulation (EU) 2017/1110 (1) please find attached the notification on changes to the membership of the management body.
— Person at the data reporting services provider in charge of preparing the notification:
Full Name:
Status/position:
Telephone:
Email:
Date:
Signed:
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— Information on member(s) leaving the management body
Member 1
Full name
Contact details (Telephone and email address)
Position
Effective date of departure from management body
Reasons for the departure from management body
Member [N]
Full name
Contact details (Telephone and email address)
Position
Effective date of departure from management body
Reasons for the departure from management body
— Information on new member(s) 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 (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 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]
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Member [N]
Full name
Date and place of birth
Personal national identification number or equivalent thereof
Private 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 Delegated Regulation (EU) 2017/571
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 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
[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]
— Complete updated list of members of the management body:
Notes: Name
Position
Effective date