CROATIAN CHAMBER of ELECTRICAL ENGINEERS Ulica Grada Vukovara 271, 10 000 ZAGREB, Tel

CROATIAN CHAMBER OF ELECTRICAL ENGINEERS Ulica grada Vukovara 271, 10 000 ZAGREB, tel.: +385 (01) 5508-444, fax.: +385 (01) 5508-441,

Application for periodic or temporary performance of works in designing and/or expert supervision of construction as a responsible person in the Republic of Croatia1

Date of receipt:
Class:
Reg.No.:
Administrative fees

1. Application refers to:

First performance of temporary services in the domicile country (please fill in 2 to 7)

Annual application renewal2 (please fill in 2 to 5 and 7)

2. Personal information:

2.1. Name and surname ……………………………………….

2.2. Citizenship:

AT BE CY CZ DE DK EE EL ES FI

FR HU IE IT LT LV LU MT NL PL

PT SI SK SE SLO UKBGROIS LI

Other …………………………………….

2.3. Passport number:Country……………………………………………

Country……………………………………………

2.4. Gender:malefemale

2.5. Date of birth:

2.6. Information on birth:Place: ………………………………………

AT BE CY CZ DE DK EE EL ES FI

FR HU IE IT LT LV LU MT NL PL

PT SI SK SE UK BG RO IS LI NO

Other …………………………………………..

2.7. Contact information in the country of seat (mandatory):

Address: …………………………………………………….

Telephone number (with area code): …………………………………………..

Fax (with area code): …………………………………………..

e-mail: ………………………………………………………

2.8. Contact information in the domicile country (optional):

Address: …………………………………………………….

Telephone number (with area code): …………………………………………

Fax (with area code): …………………………………………….

e-mail: ………………………………………………………..

3. Regulated profession i.e. activity:

3.1.Professional qualification/regulated profession3title in the domicile country4:

…………………………………………

3.2.Regulated profession i.e. activity which shall be performed in the domicile country:

………………………………………..

4. Legal seat/legal establishment in one or several countries:

For the purposes of service provider, the term “legal establishment” refers to the performance of subject activities in the member country in accordance with the rules regulating the specific regulated profession i.e. activity, including the conditions for education and all the special rules for the performance of the regulated profession i.e. activity.

4.1.Are you legally established in a member country for the performance of the profession stated in item3.14

YesNo

If the answer is yes, in which country were you legally established4?

AT BE CY CZ DE DK EE EL ES FI

FR HU IE IT LT LV LU MT NL PL

PT SI SK SE UK BG RO IS LI NO

If not, please explain: ……………………………………………..

4.2.Is theprofession regulated in the country of establishment4?

YesNo

If yes, please continue to question 4.4.

Notes: ……………………………………….

4.3.Are you a member of a professional association or a similar entity4?

YesNo

If your answer is yes, please state the name and data, as well as the registration number.

……………………………………………

…………………………………………..

4.4.Does the activityneed to be approved by the competent authority in the country of seat4?

YesNo

If your answer is yes, please state the data of the competent authority.

………………………………………….

5.Professional Liability Insurance

5.1.Do you have an insurance of any kind or another method of personal/collective insurance regarding the professional liability originating from the performance of theprofession stated in item 3.1?

YesNo

If your answer is yes, please state the following data regarding your insurance:

Name of the insurance company: ……………………………………………….

Contract number: ……………………………………………

Notes:

6.Additional documentation which shall be enclosed with the application (regional requirements)5

Certificate of citizenship (copies)
Photocopy of company registration (Decision on company registration in the court registry with a list of activities)-copies- certified translation
Chamber Resolution on the recognition of foreign professional qualification
Certificate of no criminal record6 (copies-certified translation)-not older than 6 months
Certificate of medical and professional fitness6 (copies-certified translation)
Certificate on payment of a one-year membership fee

amount:HRK 1,800.00

recipient: HRVATSKA KOMORA INŽENJERA ELEKTROTEHNIKE,

Zagreb, UlicagradaVukovara 271

account number of the recipient: HR7823600001102094148

payment description:name and surname (of the applicant)- annual membership fee

Certificate of mandatory professional liability insurance valid for the territory of the Republic of Croatia, issued in the applicant's name.
Administrative fees inthe amount of HRK 70.00

7.Information on the concerned project, estimated time of performance, information on the designer, validator, performer, supervision and investor

……………………………………………………………………………………………………………………………………..

8. Annual application renewal7

7.1. When did you provide services in the domicile country?

From / / to/ /

From/ /to/ /

From/ / to/ /

From/ /to/ /

7.2.Please state the professional activity which you performed in the period of service provision.

…………………………………………………………………………………………………………………………………………………

9.I hereby confirm that all of the above mentioned information stated in the application is true and that I intend to provide the service in a temporary manner in the Republic of Croatia.

Signature ______

Date ______

In case the competent authorities in the country of application do not issue the documents on professional, medical fitness, as well as documents on no criminal record, the applicant issues the following statement, which shall be certified by their signature.

I DECLARE WITH MY SIGNATURE THAT:

1. I AM WORTHY OF PERFORMING THE ENGINEERING WORK, I AM MEDICALLY AND PROFESSIONALLY FIT, I HAVE NOT BEEN CONVICTED FOR A CRIMINAL OFFENCE AGAINST THE REPUBLIC OF CROATIA, CRIMINAL OFFENCE AGAINST OFFICIAL DUTY OR CRIMINAL OFFENCE OUT OF SELF-INTEREST WHICH WOULD MAKE ME MORALLY UNDESERVING TO PERFORM THE ENGINEERING ACTIVITY ACCORDING TO THE PROFESSIONAL CODE OF ETHICS.

2. I DO NOT PERFORM WORK INCOMPATIBLE WITH THE ENGINEERING ACTIVITY.

3. I AGREE THAT MY PERSONAL INFORMATION MAY BE COLLECTED, PROCESSED AND KEPT BY THE CROATIAN CHAMBER OF ELECTRICAL ENGINEERS IN ACCORDANCE WITH THE PROVISIONS OF THE PERSONAL DATA PROTECTION ACT.

4. I ACCEPT THE OBLIGATION TO PERFORM WORKS IN ACCODANCE WITH THE POWERS DETERMINED BY LAW, THE CHAMBER DOCUMENTS, SPECIAL ACTS AND REGULATIONS ISSUED ON THE BASIS THEREOF.

5. UNDER CRIMINAL AND MATERIAL LIABILITY, THE ABOVE MENTIONED INFORMATION IS TRUE.

IN ______

______

signature of the applicant

1please keep a copy of this application

2please enclose the first and former/last application

3Please state the name of the profession in the language of the country of seat and the language of the domicile country.

4If your seat is located in several countries, please state the data for each individual country.

5Supplement with appropriate documents in accordance with the legislation of the domicile country for the first application for provision of services.

6 In case such certificates are not issued in the country of seat, statement certified by thenotary public

7Information shall be kept by the authority competent for supervision of service provision