Unless stated otherwise, all fields on this form are mandatory.

TO BE PRE-COMPLETED BY THE ORGANISERS:

1. All signatories on this form are

Please mark only one Member State per list.

residents in:

IE

UK

residents in or citizens of:

EE

NL

SK

FI

residents in or citizens of (citizens living abroad only if they have informed their national authorities about their place of residence):

BE

DK

DE

LU

2. European Commission registration number:

3. Date of registration:

4. Web address of this proposed citizens’ initiative in the European Commission’s register:

5. Title of this proposed citizens’ initiative:

6. Subject matter:

7. Main objectives:

8. Names and e-mail addresses of registered contact persons:

9. Names of the other registered organisers:

10. Website of this proposed citizens’ initiative (if any):

TO BE COMPLETED BY THE SIGNATORIES IN CAPITAL LETTERS:

“I hereby certify that the information that I have provided in this form is correct and that I have not already supported this proposed citizens’ initiative.”

FULL FIRST NAMES

FAMILY NAMES (2)

RESIDENCE

(street, number, postal code, city, country) (3)

DATE AND PLACE (4) OF BIRTH

NATIONALITY

DATE AND SIGNATURE (5)

(1) The form shall be printed on one sheet. Organisers may use a double-sided sheet.

(2) For the Netherlands and Slovakia, please also state the name at birth.

(3) For Finland, please only state the country of permanent residence.

(4) For Ireland, Finland and the United Kingdom, please only state the date of birth.

(5) Signature is not mandatory if the form is submitted electronically via an online collection system as referred to in Article 6 of Regulation (EU) No 211/2011.

Privacy statement: in accordance with Article 10 of Directive 95/46/EC of the European Parliament and of the Council of 24 October 1995 on the protection of individuals with regard to the processing of personal data and on the free movement of such data, the personal data provided on this form will only be made available to the competent authorities for the purpose of verification and certification of the number of valid statements of support received for this proposed citizens’ initiative (see Article 8 of Regulation (EU) No 211/2011 of the European Parliament and of the Council of 16 February 2011 on the citizens’ initiative) and, if necessary, further processed for the purpose of administrative or legal proceedings relating to this proposed citizens’ initiative (see Article 12 of Regulation (EU) No 211/2011). The data may not be used for any other purpose. Data subjects are entitled to obtain access to their personal data. All statements of support will be destroyed at the latest 18 months after the date of registration of the proposed citizens’ initiative, or, in the case of administrative or legal proceedings, at the latest one week after the date of conclusion of the said proceedings.

Unless stated otherwise, all fields on this form are mandatory.

TO BE PRE-COMPLETED BY THE ORGANISERS:

1. All signatories on this form hold personal identification numbers/personal identification document numbers of:

Please mark only one Member State per list.

BG

CZ

EL

ES

FR

HR

IT

CY

LV

LT

HU

MT

AT

PL

PT

RO

SI

SE

See Part C for personal identification numbers/personal identification document numbers, one of which must be provided.

2. European Commission registration number:

3. Date of registration:

4. Web address of this proposed citizens’ initiative in the European Commission’s register:

5. Title of this proposed citizens’ initiative:

6. Subject matter:

7. Main objectives:

8. Names and e-mail addresses of registered contact persons:

9. Names of the other registered organisers:

10. Website of this proposed citizens’ initiative (if any):

TO BE COMPLETED BY THE SIGNATORIES IN CAPITAL LETTERS:

“I hereby certify that the information that I have provided in this form is correct and that I have not already supported this proposed citizens’ initiative.”

FULL FIRST NAMES

FAMILY NAMES (2)

RESIDENCE

(street, number, postal code, city, country) (3)

DATE AND PLACE OF BIRTH (4)

NATIONALITY

PERSONAL IDENTIFICATION NUMBER/PERSONAL IDENTIFICATION DOCUMENT TYPE AND NUMBER (5)

DATE AND SIGNATURE (6)

(1) The form shall be printed on one sheet. Organisers may use a double-sided sheet.

(2) For Bulgaria and Greece, please also state the father’s name. For Greece and Latvia, please also state the name at birth.

(3) Only for France, Croatia, Italy, Austria, Poland and Romania.

(4) For Greece, Spain, Malta, Portugal and Romania, please only state the date of birth. For France, Italy, Latvia, Austria, Slovenia and Sweden, please state both the date and place of birth. For the other Member States, do not state anything.

(5) For Italian identification documents, please also state the issuing authority.

(6) Signature is not mandatory if the form is submitted electronically via an online collection system as referred to in Article 6 of Regulation (EU) No 211/2011.

Privacy statement: in accordance with Article 10 of Directive 95/46/EC of the European Parliament and of the Council of 24 October 1995 on the protection of individuals with regard to the processing of personal data and on the free movement of such data, the personal data provided on this form will only be made available to the competent authorities for the purpose of verification and certification of the number of valid statements of support received for this proposed citizens’ initiative (see Article 8 of Regulation (EU) No 211/2011 of the European Parliament and of the Council of 16 February 2011 on the citizens’ initiative) and, if necessary, further processed for the purpose of administrative or legal proceedings relating to this proposed citizens’ initiative (see Article 12 of Regulation (EU) No 211/2011). The data may not be used for any other purpose. Data subjects are entitled to obtain access to their personal data. All statements of support will be destroyed at the latest 18 months after the date of registration of the proposed citizens’ initiative, or, in the case of administrative or legal proceedings, at the latest one week after the date of conclusion of the said proceedings.