B1 Application for Permit of Entry/Drive in

to the Premises of Liberty Ostrava a.s.

based on the contract on providing of services

Applicant (the company being in a contractual relation with Liberty Ostrava a.s. or its subsidiary with headquarter in the Premises)

Company name (as per Business Register or Trades Register)	Ident. No.:
Contract no.

Applicant’s data

Headquarters (as per Business Register) or registered place of business (as per Trades Register)	VAT No.:
Postal address (if different from the headquarters or the registered place of business)
Surname and first name of the applicant’s contact person	Tel. no.
E-mail

Subcontractor’s data

Company name (as per Business Register or Trades Register)	Ident. No.:
Headquarters (as per Business Register) or registered place of business (as per Trades Register)	VAT no.:
Postal address (if different from the headquarters or the registered place of business)
Surname and first name of the subcontractor’s contact person	Tel. no.
E-mail

Subcontractor’s data

Company name (as per Business Register or Trades Register)	Ident. No.:
Headquarters (as per Business Register) or registered place of business (as per Trades Register)	VAT no.:
Postal address (if different from the headquarters or the registered place of business)
Surname and first name of the subcontractor’s contact person	Tel. no.
E-mail

Applicant’s statement

Authorized representative of the Applicant confirms that data are correct.

Surname and first name of the authorized representative of the Applicant	Stamp and signature
Tel. no.	Date

B1: Applicant’s data – filling in instructions

Identification and contact data on applicant and his subcontractors, which are necessary for issue or activation of the chip cards – authorization of entry of persons (Application marked B2) and drive in of vehicles (Application marked B3). Such Permits of Entry and Drive in are based upon valid contractual relationship with Liberty Ostrava a.s. or its subsidiary with headquarter in the Premises as per the contract number given in the heading of the sheet form. This sheet form is submitted only once. The sheet form must be submitted again only if data have been either changed or missing data have been added (for instance adding another subcontractor).

If Application for entry of persons and drive in of vehicles is based upon another reason than upon concluded contract on providing of services, then “Application for Permit of Entry/Drive in to the Premises of Liberty Ostrava a.s.” marked A will be used.

Chip cards are issued and activated at the workplace of the Entry Permit Issue Office. Contact tel. No.: 595 685 919, 595 686 019, email: povolovanivstupu.ostrava@libertysteelgroup.com.

Applicant

Applicant is a company, which has direct contractual relation with Liberty Ostrava a.s. or its subsidiary with headquarter in the Premises.

Company name: accurate company name of the Applicant as stated in the Business Register or in the Trades Register. If physical entity stands for the Applicant, then the surname and the name of the Applicant are to be provided.

Ident. No.: identification no. of the business company of the Applicant.

Contract no.: Ten-digit number of the contract is given in its heading. This is a contract concluded at the Procurement dept. of Liberty Ostrava a.s. If persons need Permit of Entry relating to several contracts (including contracts on leasing a building), then all numbers to which the Application applies must be mentioned.

Applicant’s data

Headquarters or registered place of business: accurate headquarters of the company as shown in the Business Register, and in case of a freelance person, the registered place of business as shown in the Trades Register. If physical entity stands for the Applicant, then the permanent address must be shown.

VAT No.: tax identification no. of the business company of the Applicant.

Postal address: address used for sending eventual mail. This is to be mentioned solely when being different from the headquarters or the registered place of business, and/or if the headquarters or the registered places of business are incomplete postal addresses.

Surname and first name of the applicant’s contact person: please mention a person, who is authorized and competent for discussions relating to the Entry of persons and drive in of vehicles.

Tel. no.: phone number of the contact person.

E-mail: e-mail address of the contact person. Subsequently lists of valid Permits of Entry/Drive in, lists of passes through and drive through via gatehouses of the Premises etc. are sent to this address upon request.

Subcontractor’s data

Company name: accurate company name of the Subcontractor as stated in the Business Register or in the Trades Register. If physical entity stands for the Subcontractor, then the surname and the name of the Subcontractor are to be provided.

Ident. No.: identification no. of the business company of the Subcontractor.

Headquarters or registered place of business: accurate headquarters of the company as shown in the Business Register, and in case of a freelance person, the registered place of business as shown in the Trades Register. If physical entity stands for the Applicant, then the permanent address must be shown.

VAT No.: tax identification no. of the business company of the Subcontractor.

Postal address: address used for sending eventual mail. This is to be mentioned solely when being different from the headquarters or the registered place of business, and/or if the headquarters or the registered places of business are incomplete postal addresses.

Surname and first name of the subcontractor’s contact person: please mention a person, who is authorized and competent for discussions relating to the Entry of persons and drive in of vehicles.

Tel. no.: phone number of the contact person.

E-mail: e-mail address of the contact person. Subsequently lists of valid Permits of Entry/Drive in, lists of passes through and drive through via gatehouses of the Premises etc. are sent to this address upon request.

Applicant’s statement

Authorized representative of the Applicant confirms that data are correct.