ANNEX IIISupplementary provisions
ANNEX III STATEMENT OF SUPPORT FORM — PART A (for Member States which do not require the provision of a personal identification number/personal identification document number) Text of image All fields on this form are mandatory and must be completed. TO BE PRE-COMPLETED BY THE ORGANISERS: 1. All signatories on this form are Please mark only one Member State per list. permanent residents in: IE NL UK permanent residents in or citizens of: EE FI SK permanent residents in or citizens of (citizens living abroad only if they have informed their national authorities about their place of residence): BE DK DE 2. Commission registration number: 3. Date of registration: 4. Web address of this proposed citizens’ initiative on the Commission register: 5. Title of this proposed citizens’ initiative: 6. Subject matter: 7. Main objectives: 8. Names of organisers: 9. Names and e-mail addresses of contact persons: 10. Website of this proposed citizens’ initiative (if any): TO BE COMPLETED BY THE SIGNATORIES: ‘I hereby certify that the information that I have provided in this form is correct and that I have only supported this proposed citizens' initiative once.’ Text of image FULL FIRST NAMES FAMILY NAMES ( 1 ) PERMANENT RESIDENCE (street, number, postal code, city, country) ( 2 ) DATE AND PLACE ( 3 ) OF BIRTH NATIONALITY DATE AND SIGNATURE ( 4 ) ( 1 ) For the Netherlands and Slovakia, please state also the name at birth. ( 2 ) For Finland, please state only the country of permanent residence. ( 3 ) For Finland and the United Kingdom, please state only the date of birth. ( 4 ) Signature not mandatory when form is submitted electronically without electronic signature. 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 citizen’s 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. STATEMENT OF SUPPORT FORM — PART B (for Member States which require the provision of a personal identification number/personal identification document number) Text of image All fields on this form are mandatory and must be completed. 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 IT CY LV LT LU 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. Commission registration number: 3. Date of registration: 4. Web address of this proposed citizens’ initiative on the Commission register: 5. Title of this proposed citizens’ initiative: 6. Subject matter: 7. Main objectives: 8. Names of organisers: 9. Names and e-mail addresses of contact persons: 10. Website of this proposed citizens’ initiative (if any): TO BE COMPLETED BY THE SIGNATORIES: ‘I hereby certify that the information that I have provided in this form is correct and that I have only supported this proposed citizens’ initiative once.’ Text of image FULL FIRST NAMES FAMILY NAMES ( 1 ) PERMANENT RESIDENCE (street, number, postal code, city, country) ( 2 ) DATE AND PLACE OF BIRTH ( 3 ) NATIONALITY PERSONAL IDENTIFICATION NUMBER/IDENTIFICATION DOCUMENT TYPE AND NUMBER ( 4 ) DATE AND SIGNATURE ( 5 ) ( 1 ) For Bulgaria and Greece, please state also father’s name; for Greece and Latvia, please state also the name at birth. ( 2 ) Only for Spain, France, Italy, Austria, Poland and Romania. ( 3 ) For Greece, France, Malta, Portugal and Romania, please state only the date of birth; for Luxembourg, please state only the place of birth; for Italy, Latvia, Austria, Slovenia and Sweden, please state both the date and place of birth. ( 4 ) For Italian identification documents, please state also the issuing authority. ( 5 ) Signature not mandatory when form is submitted electronically without electronic signature. 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 citizen’s 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. PART C 1. List of Member States which do not require the provision of a personal identification number/personal identification document number (statement of support form — Part A): Member State Signatories whose statement of support is to be submitted to the Member State concerned Belgium — residents in Belgium — Belgian nationals residing outside the country if they have informed their national authorities of their place of residence Denmark — residents in Denmark — Danish nationals residing outside the country if they have informed their national authorities of their place of residence Germany — residents in Germany — German nationals residing outside the country if they have informed their national authorities of their place of residence Estonia — residents in Estonia — Estonian nationals residing outside the country Ireland — residents in Ireland Netherlands — residents in the Netherlands Slovakia — residents in Slovakia — Slovak nationals residing outside the country Finland — residents in Finland — Finnish nationals residing outside the country United Kingdom — residents in the United Kingdom 2. List of Member States which require the provision of one of the personal identification numbers/personal identification document numbers, as specified below, in the statement of support form — Part B: BULGARIA — Единен граждански номер (personal number) CZECH REPUBLIC — Občanský průkaz (national identity card) — Cestovní pas (passport) GREECE — Δελτίο Αστυνομικής Ταυτότητας (identity card) — Διαβατήριο (passport) — Βεβαίωση Εγγραφής Πολιτών Ε.Ε./Έγγραφο πιστοποίησης μόνιμης διαμονής πολίτη Ε.Ε. (residence certificate/permanent residence certificate) SPAIN — Documento Nacional de Identidad (identity card) — Pasaporte (passport) FRANCE — Passeport (passport) — Carte nationale d’identité (national identity card) — Titre de séjour (residence permit) — Permis de conduire (driving licence) — Autre (other): — Carte d’identité de parlementaire avec photographie, délivrée par le président d’une assemblée parlementaire (parliamentarian’s identity card with photo, issued by the president of a parliamentary assembly), — Carte d’identité d’élu local avec photographie, délivrée par le représentant de l’Etat (elected local official’s identity card with photo, issued by the State representative), — Carte du combattant de couleur chamois ou tricolore (war veteran’s card, buff-coloured or tricoloured), — Carte d’invalidité civile ou militaire avec photographie (civilian or military invalidity card with photo), — Carte d’identité de fonctionnaire de l’Etat avec photographie (State civil servant’s identity card with photo), — Carte d’identité ou carte de circulation avec photographie, délivrée par les autorités militaires (identity card or free movement permit with photo, issued by the military authorities), — Permis de chasser avec photographie, délivré par le représentant de l’Etat (hunting permit with photo, issued by the State representative), — Livret ou carnet de circulation, délivré par le préfet en application de la loi n o 69-3 du 3 janvier 1969 (traveller’s movement permit, issued by the Prefect pursuant to Law No 69-3 of 3 January 1969), — Récépissé valant justification de l’identité, délivré en échange des pièces d’identité en cas de contrôle judiciaire, en application du neuvième alinéa (7 o ) de l’article 138 du code de procédure pénale (receipt counting as proof of identity, issued in exchange for identity documentation in cases of judicial supervision pursuant to the ninth paragraph (numbered paragraph 7) of Article 138 of the Code of Criminal Procedure), — Attestation de dépôt d’une demande de carte nationale d’identité ou de passeport, délivrée depuis moins de trois mois par une commune et comportant une photographie d’identité du demandeur authentifiée par un cachet de la commune (certificate of lodgement of an application for a national identity card or passport, issued not more than three months previously by a municipality and bearing a photo of the applicant authenticated by a municipal stamp). ITALY — Passaporto (passport), inclusa l’indicazione dell’autorità di rilascio (including issuing authority) — Carta di identità (identity card), inclusa l’indicazione dell’autorità di rilascio (including issuing authority) CYPRUS — Δελτίο Ταυτότητας (identity card of national or resident) — Διαβατήριο (passport) LATVIA — Personas kods (personal identification number) LITHUANIA — Asmens kodas (personal number) LUXEMBOURG — Numéro d’identification national (numéro inscrit sur la carte d’identification de la Sécurité sociale) (national identification number appearing on the social security identity card) HUNGARY — személyazonosító igazolvány (identity card) — útlevél (passport) — személyi azonosító szám (személyi szám) (personal identification number) MALTA — Karta tal-Identità (identity card) AUSTRIA — Reisepass (passport) — Personalausweis (identity card) POLAND — Numer ewidencyjny PESEL (PESEL identification number) PORTUGAL — Bilhete de identidade (identity card) — Passaporte (passport) — Cartão de Cidadão (citizen’s card) ROMANIA — carte de identitate (identity card) — pasaport (passport) — certificat de inregistrare (registration certificate) — cartea de rezidenta permanenta pentru cetatenii UE (permanent residence card for EU citizens) — Cod Numeric Personal (personal identification number) SLOVENIA — Osebna izkaznica (identity card) — Potni list (passport) SWEDEN — Personnummer (personal identification number) in identity card — Personnummer (personal identification number) in passport