Complaint submitted on the basis of Article 3 1

Part A: Mandatory information

1.Identification of person or entity filing the complaint

Where the complainant is a natural person, submit a form of identification. 2

Where the complaint is submitted by a body referred to in Article 80 of Regulation (EU) 2016/679, submit proof that the body has been properly constituted in accordance with the law of a Member State.

Where the complaint is submitted on the basis of Article 80(1) of Regulation 2016/679, proof that the body lodging the complaint is acting on the basis of the mandate of a data subject.

2.Contact details 3

Where the complaint is submitted electronically, email address.

Where the complaint is submitted by post, postal address.

Telephone number.

3.Entity whose processing of your personal data infringes Regulation (EU) 2016/679

Provide all information in your possession to facilitate the identification of the entity which is the subject of your complaint.

4.Subject of complaint

Please set out the facts from which, in your opinion, there is or was processing of your personal data which infringes Regulation (EU) 2016/679 (the GDPR). Indicate in particular the context in which your personal data were processed.

Part B: Supplementary information

If possible, indicate the provisions of Regulation (EU) 2016/679 (the GDPR) which you consider have been breached by the entity processing your personal data.

Please specify whether you have contacted the entity mentioned in point 3 of Part A prior to your complaint and outline the result of any such actions. If possible, please attach any relevant correspondence between you and the entity.

Please specify whether you have started other administrative and/or judicial proceedings regarding the subject matter of your complaint. If so, please provide an explanation of the status, and, where relevant, outcome of such actions.

Submit all documentation in your possession relating to the facts set out in the complaint (for example, copy of the documents attesting the relationship with the data controller (e.g. invoices, contracts); copy of any marketing messages or e-mails; pictures, photographs or screenshots; expert reports; witness reports; inspection reports).

Part C: Declaration and signature

Please confirm that the information given in this form is given entirely in good faith.

Date and signature.