Standard Formforthenotificationofhomememberstate

NotificationofHomeMemberState

Standard formforthenotificationofHomeMemberState

NOTIFICATION OF HOME MEMBER STATE (* mandatoryinformation)
1.*IssuerName:
1a.Formerlyknown as[i]
2.*Registeredoffice:
3. LEI[ii]:
3a.Nationalcompanyregisternumber[iii]
4.*Homememberstate[iv]:
5.*Triggeringevent[v]:
[]Issuerofsharesadmitted to trading(Article118 sec. 1 subsec. a) BACM[1])
[]Issuerofdebtsecuritiesdenominatedlessthan EUR 1,000 admitted to trading(Article118 sec. 1 subsec.b) BACM)
[]Issuerofothersecurities[vi](Article118 sec. 1 subsec. c) or d) BACM)
[]ChangeofhomeMemberState(Article123 sec. 4 BACM)
6.* MemberState(s) wheretheissuer'ssecurities are admitted to trading[vii]:
Shares / Debtsecurities
< 1000EUR / Othersecurities
Austria / [] / [] / []
Belgium / [] / [] / []
Bulgaria / [] / [] / []
Croatia / [] / [] / []
Cyprus / [] / [] / []
Czech Republic / [] / [] / []
Denmark / [] / [] / []
Estonia / [] / [] / []
Finland / [] / [] / []
France / [] / [] / []
Germany / [] / [] / []
Greece / [] / [] / []
Hungary / [] / [] / []
Iceland / [] / [] / []
Ireland / [] / [] / []
Italy / [] / [] / []
Latvia / [] / [] / []
Liechtenstein / [] / [] / []
Lithuania / [] / [] / []
Luxembourg / [] / [] / []
Malta / [] / [] / []
Netherlands / [] / [] / []
Norway / [] / [] / []
Poland / [] / [] / []
Portugal / [] / [] / []
Romania / [] / [] / []
Slovakia / [] / [] / []
Slovenia / [] / [] / []
Spain / [] / [] / []
Sweden / [] / [] / []
United Kingdom / [] / [] / []
6a. FormerhomeMemberState (ifapplicable)[viii]:
7.* NCAstheformisrequired to befiledwith[ix]:
8.* Dateofnotification:
9. Start date of 3 year period[x]:
10. Additionalinformation[xi]:
11.* Contactdetails:
Issuer’saddress:
Person responsiblewithintheissuerforthepresentnotification:
E-Mailaddress:
Telephone:

Notes and instructions

This standard form is derived from the model standard form published by ESMA[2],whichwillbeaccepted by the CNB as well.

The notification shall be sent to the CNB via the Internet application for Collection of information and registration of entities[3], by adding the completed form as an attachment.

Information on filingprocedures to othercompetentauthorities:

Austria / sendan e-mail to:
Belgium / sendan e-mail to:
Bulgaria
Croatia / via national OAM: SRPI; orpostaladdress: Miramarska 24b, 10000 Zagreb, Croatia
Cyprus / sendan e-mail to: (to theattentionofIssuers Department)
Denmark / website:
Estonia / sendan e-mail to:
Finland / sendan e-mail to:
France / via:
Germany / sendan e-mail to:
Greece / sendan e-mail to:
Hungary / sendan e-mail to:
Iceland / via national OAM:
Ireland / sendan e-mail to:
Italy / sendan e-mail to:
Latvia / sendan e-mail to: postaladdress: Kunguiela 1, Riga, Latvia, LV-1050
Liechtenstein
Lithuania / sendan e-mail to:
Luxembourg / sendan e-mail to:
Malta
Netherlands / sendan e-mail to:
Norway
Poland / sendan e-mail to: via ESPI system
Portugal / sendan e-mail to:
Romania / sendan e-mail to :
Slovakia / via national OAM:
Slovenia / sendan e-mail to:
Spain / on-line register:
Sweden / sendan e-mail to:
United Kingdom / sendan e-mail to:

1

[1]Act No. 256/2004 Coll., onBusiness Activities on the Capital Market (“BACM”)

[2]

[3]

[i]In case of a changeofthecompanynamecompared to thepreviousdisclosure, pleaseprovidetheissuer’sformercompanyname. In case of a firsttimedisclosure, no information on anearliernamechangeisrequired.

[ii]Legal entity identifier

[iii]In case theLEI isunavailable, pleaseprovideforidentificationpurposesthenumberunderwhichtheissueris registeredwiththe business registerofits country ofincorporation.

[iv]ThehomeMemberStatepursuant to Article123 BACM.

[v]ThecriteriauponwhichthehomeMemberState has beendetermined (mark with „X“).

[vi]Forexampledebtsecuritiesdenominatedat least EUR 1,000, unitsofcollectiveinvestmentundertakingoftheclosed end- type.

[vii]Onlysecuritiesadmitted to trading on regulatedmarketsshallbetakenintoaccount(mark with „X“).

[viii]Informationrequired in casetheissuerchooses a newhomeMemberStatepursuant to Article123 sec. 4 BACM.

[ix]According to Article123 sec. 2 BACM.

[x]In case of a choiceofhomeMemberStatepursuant to Article123 sec. 1 BACM.

[xi]Pleaseprovideanyrelevantadditionalinformation.