HRVATSKA KOMORA INŽENJERA STROJARSTVA Ulica grada Vukovara 271

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1 HRVATSKA KOMORA INŽENJERA STROJARSTVA Ulica grada Vukovara 271 CROATIAN CHAMBER OF MECHANICAL ENGINEERS CROATIA Zagreb EIN: Tel (1) VAT No: Fax (1) Web: info@hkis.hr DECLARATION OF FOREIGN PERSON AUTHORISED TO PURSUE THE REGULATED MECHANICAL ENGINEERING PROFESSION IN THE REPUBLIC OF CROATIA Form 22-1 FILLED OUT BY THE CROATIAN CHAMBER OF MECHANICAL ENGINEERS SECRETARIAT Date received: CLASS: CLASS: FILE No: FILE No: Issue date: 1. THE DECLARATION IS MADE FOR (please check): Annual renewal of the Declaration of foreign person authorised to pursue the regulated mechanical engineering profession in the Republic of Croatia 2. PERSONAL INFORMATION: FIRST NAME: LAST NAME: AT - Austria BE - Belgium BG - Bulgaria CY - Cyprus CZ Czech Republic DK - Denmark EE - Estonia FI - Finland FR - France GR Greece IE - Ireland IS - Iceland IT - Italy LV - Latvia LI - Liechtenstein LT - Lithuania LU - Luxembourg HU - Hungary MT - Malta NL - Netherlands - Norway DE - Germany PL - Poland PT - Portugal RO - Romania SK Slovakia SI Slovenia ES - Spain SE - Sweden GB Great Britain CH - Switzerland HR - Croatia Other (please specify): Personal document (please check): Identity card Passport Certificate of citizenship Sex: Male Female VAT No.: Date of birth: Country: Personal document No.: Date of expiry (MM/YYYY): Place of issue: Country of issue: Place: Citizenship: Personal taxpayer number (TIN / OIB / MBG / ID No.) Personal contact data in the home country (mandatory): Address (street and number): Postal code City: Country :

2 Contact data in the Republic of Croatia (optional): Address (street and number): Postal code PERSONAL CONTACT DATA: City: Country : CONTACT DATA IN THE COMPANY OF EMPLOYMENT: Company name: CONTACT PERSON First and last name: Remark (company name): 3. REGULATED PROFESSION OR ACTIVITY Name of professional qualification / regulated profession in the country of establishment: I hereby apply for the recognition of my qualification to pursue the following regulated profession from the Register of Regulated Professions or Professional Activities in the Republic of Croatia: (Specify in detail the name and number from the Register of Regulated Professions or Professional Activities in the Republic of Croatia) Are you qualified to pursue the abovementioned regulated profession in your home country? (please check) (If, please specify a document enclosed herewith proving the qualification and the name of the institution that issued it) Is this profession regulated in your home country? (please check) (If, please state the full name of the authority regulating the profession) Is there a formally organized education for performing the abovementioned profession in your home country that qualifies you to pursue this profession? (please check) Name of regulated profession you will be pursuing in the Republic of Croatia: Have you been authorised to pursue the regulated profession in another EU Member State? (please check) (If, please name the state and the full name of the authority that issued the authorization (evidence has to be enclosed)) 4. EDUCATION AND TRAINING DATA Name of educational institution (in native language): Address and country of educational institution: Professional title in native language: Duration of education and training:

3 Enrolment date: Graduation date: Education level acc. to EQF ECTS credits acquired: (European Qualifications Framework): Certificate of eligibility to pursue the regulated profession issued by the competent authority of the country (please enclose proof thereof) Other evidence of formal education (please enclose): Proof of contents and course of training fields and subjects (please enclose): Proof of other qualifications (please specify which and enclose): (IF THE EDUCATION LEVEL HAS CHANGED SINCE THE FIRST APPLICATION FOR PERFORMANCE OF THE REGULATED PROFESSION IN THE REPUBLIC OF CROATIA) Qualifications according to EQF European Qualifications Framework (please check): primary education Level 1 (8 years) Level 1 + vocational training for simple jobs Level 2 vocational education Level 3 (1-2 years) general secondary education Level 4 (4 years) professional higher education studies Level 5 (120 to 179 ECTS credits /more than 2, less than 3 years) undergraduate university studies and undergraduate professional studies Level 6 (180 to 240 ECTS credits / 3 4 years) graduate university studies, specialist graduate professional studies and post-master specialist university studies Level 7 (1-2 years) postgraduate research Master of Science Studies Level 8 (2 years) postgraduate university doctoral studies Level 8 (at least 3 years) 5. CROATIAN LANGUAGE PROFICIENCY Knowledge of the Croatian language (please check) If, please indicate the level A B C Language skill levels: A beginner/breakthrough; B independent user; C proficient user. If you have knowledge of the Croatian language, please specify the person whose translation services you will be using in pursuing the regulated mechanical engineering profession in the Republic of Croatia (Statement has to be enclosed)! First and last name: Company name: 6. PROFESSIONAL EXPERIENCE (professional experience in pursuing the regulated profession): Self-employed: or Employee: To (date): Company full name: Job title: Job description: 7. LEGAL ESTABLISHMENT IN ONE OR MORE STATES: Are you legally established in a EU Member State to pursue the profession under item 3.1? If, which is the Member State of establishment (name of the state)? If T, please explain:

4 Is the profession regulated in the Member State of establishment? (please check): Remark: Are you a member of any professional association or any similar organization? (please check): If, please specify full name and information on the association / organization and the registration number: Does the activity need to be approved by the relevant authority in the state of establishment? (please check): If, please specify the data on the relevant authority: 8. PROFESSIONAL LIABILITY INSURANCE: Are you covered by an insurance policy or any other personal / collective insurance against professional? Liability for pursuing the profession under Item 3? (please check): IF, YOU HAVE TO SUBMITT THE PROFESSIONAL LIABILITY INSURANCE POLICY CONCLUDED IN YOUR NAME WITH MINIMUM COVERAGE OF HRK 1,000,000 PRIOR TO TAKING OVER OF THE CERTIFICATE OF ENTRY INTO THE REGISTER. Insurance company: Policy No. /expiry date / insured perils: Remark: 9. ANNUAL RENEWAL OF THE APPLICATION (for the period in which you provided the services in Croatia date format DD/MM/YYYY) To (date): To (date) Please specify the professional activity pursued during the period in which you provided the services? 10. PLEASE ELABORATE ON THE PROFESSION YOU WISH TO PURSUE IN THE REPUBLIC OF CROATIA (description and type of work you wish to pursue): The work I wish to pursue in the Republic of Croatia (please check): design engineer construction supervisor construction engineer site (discipline) engineer 11. POWER OF ATTORNEY: First and last name of the representative: Telephone /mobile number (with dialling By signing this Declaration, I authorise the below named person as my representative to receive the documents issued by the Chamber regarding my Application!

5 BY SIGNING THIS DECLARATION: 1. I SOLEMNLY DECLARE, UNDER PENALTY OF PERJURY, THAT THE INFORMATION HEREIN CONTAINED, AND THE DOCUMENTS AND ENCLOSURES HERETO ARE TRUE AND CORRECT. 2. I AGREE THAT MY PERSONAL DATA MAY BE COLLECTED, PROCESSED AND KEPT BY THE CROATIAN CHAMBER OF MECHANCIAL ENGINEERS IN ACCORDANCE WITH THE PROVISIONS OF THE PERSONAL DATA PROTECTION ACT. 3. I AM FAMILIAR WITH LAWS AND REGULATIONS GOVERNING THE ACTIVITIES IN THE FIELD OF PHYSICAL PLANNING AND CONSTRUCTION, AND WITH THE STATUTE AND OTHER ACTS OF THE CROATIAN CHAMBER OF MECHANICAL ENGINEERS. 4. I ACCEPT THE COMMITMENT TO CONDUCT MY ACTIVITIES PURSUANT TO THE AUTHORITIES STIPULATED BY THE LAW, CHAMBER' INTERNAL RULES AND REGULATIONS, SPECIAL LAWS AND REGULATIONS ENSUING FROM SUCH LAWS. 5. I AGREE THAT MY PROFESSIONAL DATA FROM THE DIRECTORY OF THE CROATIAN CHAMBER OF MECHANICAL ENGINEERS BE MADE PUBLICALLY AVAILABLE. Place and date: Signature: Documentation enclosures are submitted in certified translation into the Croatian language accompanied by certified copies of the original documents: evidence of valid professional liability insurance with coverage of minimum HRK 1,000,000 (approx. EUR 135,000) original and/or copy of the insurance policy issued in the name and valid in the territory of the Republic of Croatia and/or EU statement on the Croatian language proficiency and/or statement on use of translation services (acc. to Item 5. above) Receipt on payment of annual membership fees in the amount of HRK 1, PAYER VAT Identification Number (mandatory) REMARK: - The VAT is not payable if the service user is a taxable person in the EU Member States or third countries. - If the service user is a non-taxable person (physical person) in the EU Member States or third countries, the VAT on the services is paid at the principal place of business of the taxable person who provided the services, or the fees are increased by the amount of VAT. - All documents should be submitted in certified translations into the Croatian language and Latin alphabet accompanied by certified copies of the original documents. Expressions that are in this application use for people in the masculine gender are neutral and apply to male and female persons. UPUTE ZA UPLATU (PAYMENT INSTRUCTIONS) Primatelj (Payee): HRVATSKA KOMORA INŽENJERA STROJARSTVA Model (Payment 00 Broj računa (Account No.): HR For international payments SWIFT: ZABAHR2X, Zagrebačka banka Poziv na broj odobrenja (Remittance advice): POREZNI BROJ UPLATITELJA (VAT Identification number of the payer) Opis plaćanja (Description): ČLANARINA I NAKNADA ZA POSTUPAK PROVJERE IZEMNE STRUČNE KVALIFIKACIJE IME I PREZIME PODSITELJA IZJAVE (MEMBERSHIP FEE AND FEES FOR CHAMBER PROCEDURE - APPLICANT S FIRST AND LAST NAME)

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