B3 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.

Vehicles Driving-in

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Remark
Ident. no. of user	Valid from	Valid until	Short-term	Permissions (see instructions)	Chip card was taken over by
A: DV: H: G:

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Remark
Ident. no. of user	Valid from	Valid until	Short-term	Permissions (see instructions)	Chip card was taken over by
A: DV: H: G:

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Remark
Ident. no. of user	Valid from	Valid until	Short-term	Permissions (see instructions)	Chip card was taken over by
A: DV: H: G:

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Remark
Ident. no. of user	Valid from	Valid until	Short-term	Permissions (see instructions)	Chip card was taken over by
A: DV: H: G:

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Remark
Ident. no. of user	Valid from	Valid until	Short-term	Permissions (see instructions)	Chip card was taken over by
A: DV: H: G:

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Remark
Ident. no. of user	Valid from	Valid until	Short-term	Permissions (see instructions)	Chip card was taken over by
A: DV: H: G:

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Remark
Ident. no. of user	Valid from	Valid until	Short-term	Permissions (see instructions)	Chip card was taken over by
A: DV: H: G:

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Remark
Ident. no. of user	Valid from	Valid until	Short-term	Permissions (see instructions)	Chip card was taken over by
A: DV: H: G:

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

B3: Vehicles Driving-in – filling in instructions

List of vehicles, for which Applicant requests issue or activation of chip cards – Drive in Permits to the Premises of Liberty Ostrava a.s. (further referred to only as Premises). Prerequisite for granting of Permit of Drive in is a valid contractual relationship with 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 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 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.

For the purpose of drive in a vehicle is a single-track motor vehicle with license plate or a two-track motor vehicle.

Usage of traffic routes in the Premises by road motor vehicles (unless specified otherwise) is subject to settlement of contractual sum depending on the category of the vehicle and the Permit’s validity. Three issues of short-term permit in of the total duration of 7 days of the given calendar month are Permitted free of charge.

Vehicles driving in to the Premises are divided into 3 categories with variable monthly settlements:

Highest permissible weight	Category	Monthly rate, VAT incl.
below 3.5 t	I	CZK 500.00
3.5 – 10 t	II	CZK 600.00
above 10 t	III	CZK 900.00

One month is understood as given calendar month, and/or its equivalent, e.g. duration of 30 days. The lowest unit is rate per 1 month. If duration exceeding 1 month is requested, then the settlement is rounded upwards to the entire multiples of monthly rates.

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 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.

Vehicles Driving-in

Motor vehicle license: license plate, and/or state number plate of the vehicle as per the technical registration papers of the vehicle. In case of vehicles, which do not have this license plate, please provide registration no. of this vehicle.

Type of vehicle: please provide type of vehicle as given in the table (according to the technical registration papers of the vehicle)

O	Personal	N	Truck	T	Tractor	P	Working machine
A	Bus	S	Special	M	Motorcycle	X	Others

Vehicle make and model: brand name and vehicle model as per registration papers of the vehicle (for instance Skoda Octavia, Ford Focus, Volkswagen Passat etc.)

Category: vehicle category is to be mentioned here based on the highest permitted weight as given in technical registration papers of the vehicle as given in the above shown table (vehicle up to 3.5 tons = category I etc.)

Ident. no. of user: identification no. of the business company, which uses the vehicle for securing of its activities in the Premises. Please do not fill in if the identification no. of user is identical with the identification no. of 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 vehicles, then it is enough to fill this information only for the first one.

Short-term: please fill in YES, if issue of long-term Drive in Permit is not requested.

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

A	Main Premises	H	Slag management (dump yard)
DV	Mine supports and road crash barriers	G	Road transport (garages)

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

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.