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Sheet No 1 : application to be kept by the issuing authority (indicate in each Member State the identity of that authority); in the case of additional lists, as many sheets No 1 as necessary must be used; it is up to the competent issuing authorities to establish whether more than one export licence should be issued,

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Sheet No 2 : to be presented in support of the export declaration at the competent customs office of export and kept by the licence holder after it has been stamped by that office,

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Sheet No 3 : to be presented at the competent customs office of export and to accompany the consignment thereafter until its arrival at the customs office of exit from the customs territory of the Union; the customs office of exit stamps this sheet and then returns it to the issuing authority.

Box 1:

Applicant: Name of individual or company and full residential address or address of company headquarters

Box 2:

Export licence: For completion by competent authorities

Box 3:

Consignee: Name and full address of consignee, including the third country to which the good is being permanently or temporarily exported

Box 4:

Indicate whether export is permanent or temporary

Box 5:

Issuing authority: Name of the competent authority and the Member State issuing the authorisation

Box 6:

Applicant’s representative: To be completed only where the applicant is using an authorised representative

Box 7:

Owner of the object(s): Name and address

Box 8:

Description in terms of Annex I to Regulation (EC) No 116/2009. Category(ies) of cultural good(s): These goods are classified in categories numbered 1 to 15. Enter only the corresponding number.

Box 9:

Description of the cultural good(s): State the exact nature of the good(s) (for example painting, sculpture, bas-relief, negative matrix or positive copy in the case of films, furniture or objects, musical instruments) and give an objective description of the appearance of the good(s).

If there is not enough room to describe all the objects, the applicant must add any extra pages needed.

Box 10:

CN code: As an indicator, state Combined Nomenclature code.

Box 11:

Number/quantity: State the number of items, particularly where they form a set.

In the case of films, indicate the number of reels, format and length.

Box 12:

Value in national currency: State the value of the good(s) in national currency.

Box 13:

Purpose of export of the cultural good(s)/reason for which the licence is requested: State whether the good to be exported has been sold or is intended to be sold, exhibited, valued, repaired or put to any other use, and whether its return is compulsory.

Box 14:

Title or subject: If the work does not have an exact name, indicate its subject with a summary of the appearance of the object or, in the case of films, the subject.

For scientific instruments or other objects for which it is not possible to specify a title or subject, it is sufficient to complete box 9.

Box 15:

Measurements: Measurements (in centimetres) of the good(s) and any supports.

In the case of complex or unusual shapes, indicate the measurements in this order: H x L x D (height, width, depth).

Box 16:

Dating: Where no precise date is known, indicate the century and part of the century (first quarter, first half) or millennium (categories 1 to 7).

For antique goods to which age specifications apply (more than 50 or 100 years old or between 50 and 100 years old), and for which it is not sufficient to indicate the century, specify a year, even if approximate (for example around 1890, approximately 1950).

For films, if date not known, specify decade.

In the case of sets (archives and libraries), indicate earliest and latest dates.

Box 17:

Other characteristics: Give any other information on formal aspects that could be useful for identification, for example historical antecedents, conditions of execution, former owners, state of preservation and restoration, bibliography, electronic code or marking.

Box 18:

Documents submitted/specific indications relating to identification: Indicate with crosses in the appropriate squares.

Box 19:

Artist, period, workshop and/or style: Give the artist’s name if known and recorded. If the works are collaborative products or copies, indicate the artists or the artist copied, if known. If the work is only attributed to a single artist, enter ‘Attributed to […]’.

If the artist is not known, state the workshop, school or style (for example workshop of Velazquez, Venetian school, Ming period, Louis XV-style or Victorian-style).

In the case of printed matter, state the name of the publisher, the place and the year of publication.

Box 20:

Medium or technique: The information given in this box must be as precise as possible. Indicate the materials used and specify the technique employed (for example oil painting, woodcuts, charcoal or pencil drawing, lost wax casting, nitrate film, etc.).

Box 21

(sheet 1): Application: Must be completed by the applicant or his/her representative, who must vouch for the correctness of the information supplied in the application and supporting documents.

Box 22:

Signature and stamp of issuing authority: To be entered by the competent authority, with place and date, on the three sheets of the licence.

Box 23

(sheets 2 and 3): For completion by customs office of export: To be entered by the customs office where the export transactions are carried out and the export licence is presented.

‘Customs office of export’ means the office where the export declaration is submitted and export formalities are carried out.

Box 24:

Photograph(s) of the cultural good(s): A colour photograph (at least 9 x 12 cm) must be attached with glue. To facilitate the identification of three-dimensional objects, photographs may be required of the different facets.

The competent authority must endorse the photograph with a signature and the stamp of the issuing authority.

The competent authorities may require other photographs.

Box 25:

Supplementary pages: State the number of additional pages used, if any.

Box 26

(sheets 2 and 3): Customs office of exit: To be completed by the customs office of exit.

‘Customs office of exit’ means the last customs office before the goods leave the customs territory of the Union.