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1. Name: Function/position: Company: Address: Tel.: E-mail: Date: Nature of business: Category of interested party (see Annex II to Regulation (EU) No 376/2014 of the European Parliament and of the Council of 3 April 2014 on the reporting, analysis and follow-up of occurrences in civil aviation ()): 2. Information requested (please be as specific as possible; include the relevant date/period in which you are interested):

3. Reason for the request: 4. Explain the purpose for which the information will be used: 5. Date by which the information is requested: 6. The completed form should be sent, via e-mail, to: (point of contact) 7. Access to information The point of contact is not required to supply any requested information. It may do so only if it is confident that the request is compatible with Regulation (EU) No 376/2014. The requestor commits itself and its organisation to restrict the use of the information to the purpose it has described under point 4. It is also recalled that information provided on the basis of this request is made available only for the purposes of flight safety as provided in Regulation (EU) No 376/2014 and not for other purposes such as, in particular, attributing blame or liability or for commercial purposes. The requestor is not allowed to disclose information provided to it to anyone without the written consent of the point of contact. Failure to comply with these conditions may lead to a refusal of access to further information from the European Central Repository and, where applicable, to the imposition of penalties

8. Date, place and signature: () Regulation (EU) 2018/1139 of the European Parliament and of the Council of 4 July 2018 on common rules in the field of civil aviation and establishing a European Union Aviation Safety Agency, and amending Regulations (EC) No 2111/2005, (EC) No 1008/2008, (EU) No 996/2010, (EU) No 376/2014 and Directives 2014/30/EU and 2014/53/EU of the European Parliament and of the Council, and repealing Regulations (EC) No 552/2004 and (EC) No 216/2008 of the European Parliament and of the Council and Council Regulation (EEC) No 3922/91 (OJ L 212, 22.8.2018, p 1). () Regulation (EC) No 1008/2008 of the European Parliament and of the Council of 24 September 2008 on common rules for the operation of air services in the Community (OJ L 293, 31.10.2008, p 3). () OJ L 122, 24.4.2014, p. 18.