USER AGREEMENT BE

Fill out the form and mark by circling your choice

Company

Company full name :

Acronym (max. 15 characters):

Postal address:

E-mail address:

Member state of submission: Belgium (BE)

Importer or Manufacturer?:ImporterManufacturer

Your bBank account + IBAN number:

Smart card to be issued and sendt to

Surname (Family name):

First name:

Postal address (if different than company’s address):

E-mail address:

Are you submitting also information related in to other Member states?Yes No

Do you already have a valid EMTOC smart card?YesNo

Please send to EMTOC Trust Centre by e-mail:

(1) the duly signed User Agreement as scanned pdf.

(2) the filled ‘Form for contact details’ as Word document (see

For questions: contact the Trust Centre:

Submit the application form to the authority / regulator of the Member State (MS) in which you wish to submit yourrelated to data to be submitted. Submit one application form for each MS. Following approval by the authority / regulator of the MS, the Trust Centre will grant you limited access to the EMTOC system for the particular MS. For multiple MS, you will need only one smart card and one PIN. H, however you will receive a unique UserID and password for each MS. Contact the Trust Centre to apply for additional smart cards ().

For the Belgium you need NOT to transfer a fee.

The fees for the use of the EMTOC-system (the administrative costs of € 200 per MS) are to be transferred to the bank account of the RIVM at the Royal Bank of Scotland, ABN AMRO N.V. Gustav Mahlerlaan 10, 1081 PP Amsterdam, The Netherlands.

IBAN: NL58RBOS0569998921. BIC/SWIFT code: RBOSNL2A

Please mark on the payment sheet: EMTOC and for which Member States fees are transferred.

Account holder: RIVM (mark on transfer sheet: “EMTOC” and Member States concerned).

I have read the “EMTOC Terms of Use” and the “EMTOC Instructions” (see also , I accept the Terms of Use and I declare that the fee has been transferred to the Trust Centre.

To be signed by an authorized representative of the company. (also on behalf of all other users affiliated to the user’s Company).

……………………………...... ……………….……………………..

SignatureDatePlace

…………………………………….

(insert authorised representatives name)

You need not to sign a User Agreement, if you have submitted this form to a competent authority before.