Domicile Address: Correspondence Address

Domicile address: Correspondence address:

1/Interest rate „turbo“ = posibility of an extra instalments free of charge.

From which required for the purpose of (state the amount for respective purposes in CZK):

Other collateral: Other sources

(except the subject mortgage loan) Own sources

4/ For possible extra works

We are interested in concluding Raiffeisen TRIGA PLUS insurance from UNIQA pojišťovna, a.s. to the below extent:

I/We agree to mutual exchange of personal data related to the insurance and the mortgage loan between UNIQA pojišťovna, a.s. and Raiffeisenbank a.s. (applies only in case of concluding Raiffeisen TRIGA PLUS insurance).

Other required documents are attached to this application.

(i)  I agree that the Bank will gather, process and store my personal data including the birth number for the below purpose and in the way, to the extent and under the conditions as stated in the Information Memorandum of the Banking Client Information Register and the Non-banking Client Information Register (hereinafter the “Information Memorandum”). The purpose of processing my personal data based on this consent is securing mutual information to authorized users of the Banking Client Information Register (hereinafter “BCIR”) and the Non-banking Client Information Register (hereinafter “NCIR”) about my credit score, credibility and payment behaviour and allowing (repeatedly as well) evaluation of my credit score, credibility and payment behaviour by authorized users of BCIR and NCIR. The way, extent and conditions of mutual provision of information among authorized users of BCIR and NCIR are given in the Information Memorandum.

(ii)  I also agree that in case of breaching my contractual obligation resulting in existence of a financial receivable of the Bank from me in the amount of two instalments past due or any financial receivable more than 30 days past due, the Bank will process my personal data to the extent of: first name, last name, address, date of birth, birth number, company ID No., information about the extent and nature of the breach, in particular the type of breached obligation, date of occurrence and fulfilment of the breached obligation and the due amount. The Bank will process these personal data for the purpose of providing information about the breach of my contractual obligation and for the purpose of protecting the Bank’s rights and will be provided for the said purposes for further processing to the association SOLUS, z.s.p.o, company ID No.: 69346925 (hereinafter „SOLUS“), of which the Bank is member and which maintains a database of debtors who have violated their contractual obligation to pay properly for a rendered service (i.e. a loan, hire purchase, insurance, credit cards, purchase by instalments, electronic communications

services, provision of utilities, etc.), or to the legal successor of SOLUS. I agree that SOLUS will employ services of processors to process the personal data. I agree that SOLUS will make such processed personal data, including the birth number,available to its

members solely for the said purposes. The current list of members of SOLUS is available at www.solus.cz and in the Bank’s registered office

(iii) I agree the bank will acquire information about my solvency (including information about the nature and extent of possible breaches of past obligations), payment morale and credibility, required for evaluating my application for the service. The information will be acquired from the negative database of the association SOLUS.

(iv) I grant the consent according to point (i) for 4 years from the date when granted; if concluding the Agreement, I grant the consent for the term thereof and the next 4 years after fulfilling my financial obligations under the Agreement if such obligations will cease by fulfilment or in a substitute way to fulfilment, or after termination of the Agreement if financial obligations under the Agreement will cease otherwise.

(v) I grant the consent according to point (ii) for 3 years from the date when granted; if concluding the Agreement, I grant the consent for the term thereof and the next 3 years after fulfilling my financial obligations under the Agreement if such obligations will cease by fulfilment or in a substitute way to fulfilment, or after termination of the Agreement if financial obligations under the Agreement will cease otherwise.

(vi) An agreement according articles (i) – (v) of this clause is also applied on bank’s product – credit card, that will be issued to applicant/co-applicant if conditions defined by bank are fulfilled.

(vii) I hereby confirm that before signing the consents I was informed about my rights related to processing my personal data according to the Act on the protection of personal data. I have also read theInformation Memorandum, which contains a notice of my rights in relation to processing my personal data within BCIR and for the purposes of mutual provision of information among users of BCIR and/or NCIR, provided that the current wording of the Information Memorandum is available anytime at www.rb.cz or at the branch offices of Raiffeisenbank a.s.

I hereby undertake to provide cooperation in presenting other documents required by the bank. I represent that as of the time of submitting the application an execution on my property was neither adjudicated nor performed. Furthermore, I represent that the above information is true and accurate and that I do not keep secret any facts, which could affect an appreciation of this application. I undertake to inform Raiffeisenbank a.s. about any change thereof without undue delay. I also agree with preparing business and services offers and with sending such offers.

Signature of the applicant

I represent that I am not a person with special relationship to the bank I am a person with special relationship to the bank.

I hereby confirm that the Raiffeisenbank a. s. mortgage loan for which I am applying by means of this Application for a Mortgage Loan for a Natural Person was not / was brokered for me by one of the bank’s external sales representatives, and I also declare that this sales representative is the only person for whom I have signed confirmation. Identification of sales representative:

I give my consent to Raiffeisenbank a.s. submitting information and data subject to bank secrecy and data protection to the company specified above in connection with the brokerage activities referred to above. This information and data relates to my Application for a Mortgage Loan for a Natural Person. Specifically it involves data on the state of negotiations and approval of the application, as well as data relating to the contract and the implementation thereof concluded subsequently on the basis of my application, this for the purpose of brokering and concluding the contract and cooperation during implementation of the contract, especially the fixing of the first payments. This consent will apply for 3 months of being granted and if a contract on the provision of a mortgage loan is concluded within this period of time, will apply for a further 5 years of this contract being concluded.

Signature of the applicant

I represent that I have verified the information sated in the application against the proof of identity and the information COMPLIES / DOES NOT COMPLY 5/ with data stated in the above verified proof of identity.

5/ strike out the inapplicable option.

NON-COMPLIANT data: …………………………………………………………………………………………………………………………………………..

Name of the identifying person His / her signature

Application for a mortgage loan, version 20140101 page 5 of 5