B2 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.

Entry of persons

First name	Surname, title	Date of birth	Profession	Signature *
Employer Ident. no.	Valid from	Valid until	Permissions (see instructions)	Chip card was taken over by
A: Ř: DV: H: G: FM:

First name	Surname, title	Date of birth	Profession	Signature *
Employer Ident. no.	Valid from	Valid until	Permissions (see instructions)	Chip card was taken over by
A: Ř: DV: H: G: FM:

First name	Surname, title	Date of birth	Profession	Signature *
Employer Ident. no.	Valid from	Valid until	Permissions (see instructions)	Chip card was taken over by
A: Ř: DV: H: G: FM:

First name	Surname, title	Date of birth	Profession	Signature *
Employer Ident. no.	Valid from	Valid until	Permissions (see instructions)	Chip card was taken over by
A: Ř: DV: H: G: FM:

First name	Surname, title	Date of birth	Profession	Signature *
Employer Ident. no.	Valid from	Valid until	Permissions (see instructions)	Chip card was taken over by
A: Ř: DV: H: G: FM:

First name	Surname, title	Date of birth	Profession	Signature *
Employer Ident. no.	Valid from	Valid until	Permissions (see instructions)	Chip card was taken over by
A: Ř: DV: H: G: FM:

* I confirm with my signature that I have made myself acquainted and will adhere to the Basic Rules for Entry and Stay of Persons in Liberty Ostrava a.s. I also acknowledge that Liberty Ostrava a.s., Company ID 451 93 258 (hereinafter the Controller), as the Controller and FENIX INTERNATIONAL, spol. s r.o. Company ID: 186 30 995 (hereinafter referred to as "the Processor") as the processor are authorized to process the data concerning me ("Data") that are required for the safe entry, transit, movement or proper performance of my activity in the premises of Liberty Ostrava ant to the registration of persons entering these Premises (hereinafter referred to as the "Purpose"). This processing is thus based on these legitimate interests of the Controller. The personal data can be transmitted to third person in the premises in whose interest the entry permit was granted. Processing will take place for the duration of the authorization and for subsequent 3 years. I further declare that I was acquainted with my right of access to the data, the right to rectification, the limitation of the processing, the addition or deletion, and the right to file a complaint with the Office for Personal Data Protection. I hereby confirm that the provided data concerning me are true.

Applicant’s statement

Authorized representative of the Applicant confirms that data are correct and also bears responsibility for informing the mentioned persons about the basic rules valid for entry and stay of persons in the Premises of Liberty Ostrava a.s.

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

B2: Entry of persons – filling in instructions

List of persons for which the Applicant requires issue or activation of chip cards – Entry Permit to the Premises of Liberty Ostrava a.s. Prerequisite for granting of Permit of Entry is a valid contractual relationship with company of Liberty Ostrava a.s. or its subsidiary with headquarter in the Premises as per the number of contract mentioned in the heading of the sheet form and submitting of the filled in Application marked B1. If application for entry of persons and drive in of vehicles is based upon another reason than on 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 bear photo of the person. Based on this fact the Applicant must on his own initiative get the necessary information and agree upon the date of taking the picture at the photo-workplace, which is located at the building of the Entry Permit Issue Office. Permits are never sent by mail and the Applicant must agree upon the date of their taking over.

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 Permits of Entry relating to several contracts (including contracts on leasing a building), then all numbers to which the Application applies must be mentioned.

Entry of persons

Profession: profession which the person will carry out in the Premises of Liberty Ostrava a.s.

Signature: signature of the person for which the long-term permit is required.

Employer Ident no.: identification no. of the business company with which the person concluded work contract (work agreement, contract on providing services), and/or identification no. of a freelance person if the service is provided based on Business authorization document. This is not filled out if the identification no. of the employer is identical with the identification no. of the Applicant.

For every given ident. no. of the employer it is necessary to fill in the Application, part called Data on Applicant, where data of the specific subcontractor are mentioned.

Valid from, Valid until: initial and final date of the Drive in Permit validity. Period for which the Permit of Drive in of the specific vehicle is inevitably necessary is mentioned here. If the required period of validity is identical for all shown persons, then it is enough to fill this information only for the first one.

Permissions: mark the area, to which the Permit of Entry is required in link with fulfilment of the subject of the contract, by cross:

A	Main Premises
Ř	Headquarters of Liberty Ostrava a.s.
DV	Mine supports and road crash barriers
H	Slag management (dump yard)
G	Road transport (garages)
FM	Office building in Frýdek-Místek

If the required areas for Permit of Entry are identical for all specified persons, then it is enough to fill in this information only for the first person.

Chip card was taken over by: Mention date of taking over of the issued chip card and signature of the person, who takes the card over.

Applicant’s statement

Authorized representative of the Applicant confirms that data are correct and also bears responsibility for informing the mentioned persons about the basic rules valid for entry and stay of persons in the Premises of Liberty Ostrava a.s.