22. Richard Slager; Corona, bijlage 1

ENG-2021/1

Application Form

-I 1*1 'l‘l - i \ (.Ų;ř «Jf HUMAN KX-H IŞ

'-OUÁ fcUKWĹUs Mits DHOI lì»-*LL H-JXML

About this application form This lam» 4,1 four».» legal document and may affect your rights and obligations. Please follow the instructions given in the "Metes for filing in the application foim*. Maly yjrc yuu Til in a I (ho fields applicable to your situation and provide all relevant doc.,meats.

Warning: f your application s ncomplete. it will not oe accepted (sec Rule 47 ol the Rules of Court) Please note n part lulur that Hule 4/ 5 2 |a; requi'es that a concise statement of faces, complaints and nlor-aliori about compliance with Ihu admissibility criteria MUSI be or» The relevant parts of the appl cation lorm licit. The completed form should enable the Court to deter'’ire the nature and scope of the application without recount; to any other submissions

Barcode label

Reference number

If you have already received a sheet of barcode labels from rhe European Cuuil o' Hum,m Rights, please place one barcode label in the box below.

if you already have a reference number from the Court In relation to these complaint*, please indicate it in the bo» below

11 pi i min «fit/?! Mel (loan

M.D

A. The applicant A.1. Individual

A.2. Organisation

This section refers to applicants who are individual persons only, if the applicant is an organisation, please go :o section A.2.

This section should oniy be filled in where the applicant is a comoanv. NGG, association o. other legal entity. In this case, please also fill in section D.l.

1. Surname

10. Nome

ţAeGáO'-r l. rirsr name(s) 1J. identif ration number |l‘ any)

W-s/V.

î. Hate of birth eft. 31.12 19GC c

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w

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17. !7aio 11I reghirallon nr Incorporation lit any)

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4. Place olb rth

ll

II

l 2- O V C\ *â- ” 09 ’013

V

M

V

V

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13 Activity

ċľoowVí 'MG -

S. Nationality

L4. Registered address 6. Address

k)ĉ^«Wo4 o 7. telephone {ncludlng international dialling code! 15. telephone [including international diallingcode) Otfb\ ćaA^é6A9ö 8. Email i ll any) 16. Email 0. Sex

male

fe'iale

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