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Surname/Last name

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First name

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Date of birth

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Sex: male/female/unknown

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Personal identification number

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Place of birth

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Nationality

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The person resides legally in a Member State (for third-country nationals)

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Address in the State of residence (at least town, postal code, country)

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Address in the State of stay (at least town, postal code, country)

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Contact address of the person

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Job-title/Profession/Trade

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Employer

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Self-employment activity

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Starting/ending date of work

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Employer (employing administration)

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Place(s) of work abroad (repeat as many times as needed)

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Starting date of work abroad

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Ending date of work abroad

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Employer

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Name of the vessel

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The State of which the vessel is flying the flag

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The remuneration is paid by the undertaking whose registered office or place of business is in another State: yes/no

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Starting date of work

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Ending date of work

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Employer

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Place where the home base is situated

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Starting date of work

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Ending date of work

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Employer in the posting State

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Undertaking(s) in the receiving State/place(s) of posting

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Starting date of posting

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Ending date of posting

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The employee is subject to legislation of the posting State within one month before posting: yes/no

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Details of activity performed one month immediately prior to posting

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Nature of activity in posting State

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Nature of activity in receiving State

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The employee is being posted to replace another posted worker: yes/no

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If yes, please indicate, why this replacement is deemed necessary

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The employee has already worked in the receiving Member State concerned: yes/no

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If yes, indicate the previous periods of posting (date from, date to)

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Number of employees of the employer in the posting State (excluding administrative workers)

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number of administrative workers in the posting State

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Number of posted employees

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Number of contracts exercised in the posting State

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Number of contracts exercised in the receiving State

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Turnover in the posting State (in %)

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Turnover in the receiving Member State (in %)

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The employer in posting State may decide to terminate the contract with the employees during their posting: yes/no

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The employer in posting State is able to decide the key aspects of the activity performed in the receiving State: yes/no

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The employment contract is concluded with: the employer in the posting State/the undertaking in the receiving State

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The employee will be paid by: the employer in the posting State/the undertaking in the receiving State

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Will the employment relationship continue during the period of posting: yes/no

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Will the undertaking to which the employee is posted place him at the disposal of another undertaking: yes/no

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Self-employment in the posting State

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Self-employment in the receiving State/Place of posting

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Starting date of posting

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Ending date of posting

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The self-employed has already worked in the receiving Member State: yes/no

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If yes, indicate the previous periods of posting (date from, date to)

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During the posting, a business structure will be maintained in the posting State, so that business activity can be resumed on return from abroad: yes/no

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Business activity will be resumed on return from the receiving Member State

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Nature of activity in posting State

Nature of activity in receiving State

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Employer

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States where work is performed

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Details regarding place(s) of work (repeat as many times as needed)

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States where activities accounting for less than 5 % of the worker’s regular working time and/or less than 5 % of overall remuneration

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Starting date of work in each undertaking

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Ending date of work in each undertaking

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Employer(s) (repeat as many times as needed)

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Statistical Classification of Economic Activities in the European Community of the employer according to NACE

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States where work is performed

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Details regarding place(s) of work (repeat as many times as needed)

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States where activities accounting for less than 5 % of the worker’s regular working time and/or less than 5 % of overall remuneration

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States where activities accounting for at least 25 % of the worker’s regular working time and/or at least 25 % of overall remuneration

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Starting date of work in each undertaking

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Ending date of work in each undertaking

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Self-employment activity

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Statistical Classification of Economic Activities in the European Community of the self-employment according to NACE

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States where work is performed

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Details regarding place(s) of self-employment activity (repeat as many times as needed)

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Turnover and/or income in each State where activity is performed

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Working time in each State where activity is performed

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Number of services rendered in each State where activity is performed

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Starting date of activity

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Ending date of activity

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Self-employment activity (repeat as many times as needed)

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Employer (repeat as many times as needed)

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Statistical Classification of Economic Activities in the European Community of the employer according to NACE

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States where work is performed

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Details regarding places of activity (repeat as many times as needed)

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States where activities accounting for less than 5 % of the worker’s regular working time and/or less than 5 % of overall remuneration

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States where activities accounting for at least 25 % of the worker’s regular working time and/or at least 25 % of overall remuneration

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Starting date of activity

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Ending date of activity

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Employer (employing administration)

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Self-employment activity and/or employment activity (repeat as many times as needed)

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Starting date of work

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Ending date of work

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Employer (employing EU institution or body)

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Place of work abroad

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Starting date of work as contract Staff of the European Union

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The legislation for which the person concerned opted: the legislation of the State in which he/she is employed/the legislation of the State to which he/she was last subject/the legislation of the State of his/her nationality

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‘I declare that the information on this form is true and complete.’

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‘I have answered all the questions correctly to the best of my knowledge.’

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‘I declare that I am aware of the possibility of checks throughout the period of posting so as to ascertain that this period has not come to an end. Such checks may relate, in particular, to the payment of contributions and to the maintenance of the direct relationship.’

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‘As employer of the posted employee, I declare that the information is complete and correct. I am aware of the fact, that the provided information may be scrutinised in <name of the posting Member State> as well as in the receiving State by the competent institution. If the provided information is not in accordance with the factual situation, the document regarding the applicable legislation can be withdrawn retroactively. In this case, the legislation of the receiving State where the employment is actually performed will be applicable. I commit myself to inform the competent institution in <name of the posting Member State> (i) if the employee has not been posted or if the posting period is interrupted for more than two months or (ii) if the posting is terminated before the end of the presumed posting period.’

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‘I declare that I am aware of the possibility of checks throughout the period during which I pursue a temporary activity in the State in which I am active, so as to ascertain that the conditions applying to that activity have not changed. Such checks may relate, in particular, to the payment of contributions and the maintenance of the infrastructure needed to pursue the activity in the State in which I am established.’

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‘I declare that the information is complete and correct. I am aware of the fact that the provided information may be scrutinised in <name of the posting Member State> as well as in the receiving State of employment by the competent institution. If the provided information is not in accordance with the factual situation, the document regarding the applicable legislation can be withdrawn retroactively. In this case, the question which legislation is applicable will have to be determined again on the basis of the factual circumstances. I commit myself to inform the competent institution of <name of the posting Member State> about all changes regarding the employment relationship (i.e. change of employer, change of the centre of interests, change of working hours, taking up new activities).’