Surname and given name of applicant
I. Personal data: Co-applicant Co-applicant
Title before the name
Surname
Maiden name
Given name
Title after the name
Birth number
Company ID No.
Citizenship
Relation to the subject of the loan / Future owner
Tenant / Owner None / Future owner
Tenant / Owner None
Date of birth (in case of unknown birth number)
Sex / Male / Female / Male / Female
Client of Raiffeisenbank / Yes / No / Yes / No
II. Additional data:
Place of birth
Country of birth
Education / Elementary
Vocational
Vocational grad. / High school grad.
College
University / Elementary
Vocational
Vocational grad. / High school grad.
College
University
Relation to the applicant / Husband / wife
Common-low spouse / Relative
Other / Husband / wife
Common-low spouse / Relative
Other
Marital status / Single
Divorced / Widowed
Married / Single
Divorced / Widowed
Married
Number of dependent children
Type of current housing / Cooperative flat
Municipal flat
Leased / With parents
Own house / flat
Other / Cooperative flat
Municipal flat
Leased / With parents
Own house / flat
Other
Term of current housing / Years: / Months: / Years: / Months:
III. Income information:
Main income / Pensioner Unemployed
Entrepreneur
Student / Household
Employee
Other ______
______/ Pensioner Unemployed
Entrepreneur
Student / Household
Employee
Other ______
______
Term of current employ-ment / entrepreneurship / Years: / Months: / Years: / Months:
Term of experience in the industry / Years: / Months: / Years: / Months:
Industry of the employer or the business / Transport
Utilities
Trade
Finance
Restaurants,
tourism
Services, telecomm / Civil engineering
Heavy industry,
mining
Health
Agriculture, forestry
Manufacturing
Other / Transport
Utilities
Trade
Finance
Restaurants,
tourism
Services, telecomm / Civil engineering
Heavy industry,
mining
Health
Agriculture, forestry
Manufacturing
Other
State employee / Yes No Unassigned / Yes No Unassigned
Job position / Administration
Worker
Director / Middle / Higher
management
Freelance
Other ______/ Administration
Worker
Director / Middle / Higher
management
Freelance
Other ______
Term of previous employment / Years: / Months: / Years: / Months:
IV. Domicile address:
Country
Street
House number
City / post office
District / Postal code
V. Correspondence address in the Czech republic and contact data:
Street
House number
City / post office
District / Postal code
Mobile phone 1/ / Invoice Pre-paid / Invoice Pre-paid
Home telephone number 1/
Work telephone number 1/
E-mail address

1/ At least one phone contact has to be written

VI. Existing liabilities:

Current amount/limit Monthly instalment Current amount/limit Monthly instalment

Mortgage loans
Consumer loans
Loans under building saving schemes
Cash loans, purchases by installments
Installment cards
Personal hire-purchase
Other liabilities / loans
VII. Miscellaneous:

Other required documents are attached to this application.

(i) I agree that the Raiffeisenbank a.s. (hereinafter the “Bank”) will gather, process and store my personal data including the birth number for the below purpose and in the way, to the extent and under the conditions as stated in the Information Memorandum of the Banking Client Information Register and the Non-banking Client Information Register (hereinafter the “Information Memorandum”). The purpose of processing my personal data based on this consent is securing mutual information to authorized users of the Banking Client Information Register (hereinafter “BCIR”) and the Non-banking Client Information Register (hereinafter “NCIR”) about my credit score, credibility and payment behaviour and allowing (repeatedly as well) evaluation of my credit score, credibility and payment behaviour by authorized users of BCIR and NCIR. The way, extent and conditions of mutual provision of information among authorized users of BCIR and NCIR are given in the Information Memorandum.

(ii) I also agree that in case of breaching my contractual obligation resulting in existence of a financial receivable of the Bank from me in the amount of two instalments past due or any financial receivable more than 30 days past due, the Bank will process my personal data to the extent of: first name, last name, address, date of birth, birth number, company ID No., information about the extent and nature of the breach, in particular the type of breached obligation, date of occurrence and fulfilment of the breached obligation and the due amount. The Bank will process these personal data for the purpose of providing information about the breach of my contractual obligation and for the purpose of protecting the Bank’s rights and will be provided for the said purposes for further processing to the association SOLUS, z.s.p.o, company ID No.: 69346925 (hereinafter „SOLUS“), of which the Bank is member and which maintains a database of debtors who have violated their contractual obligation to pay properly for a rendered service (i.e. a loan, hire purchase, insurance, credit cards, purchase by instalments, electronic communications services, provision of utilities, etc.), or to the legal successor of SOLUS. I agree that SOLUS will employ services of processors to process the personal data. I agree that SOLUS will make such processed personal data, including the birth number, available to its members solely for the said purposes. The current list of members of SOLUS is available at www.solus.cz and in the Bank’s registered office

(iii) I agree the bank will acquire information about my solvency (including information about the nature and extent of possible breaches of past obligations), payment morale and credibility, required for evaluating my application for the service. The information will be acquired from the negative database of the association SOLUS.

(iv) I grant the consent according to point (i) for 4 years from the date when granted; if concluding the Agreement, I grant the consent for the term thereof and the next 4 years after fulfilling my financial obligations under the Agreement if such obligations will cease by fulfilment or in a substitute way to fulfilment, or after termination of the Agreement if financial obligations under the Agreement will cease otherwise.

(v) I grant the consent according to point (ii) for 3 years from the date when granted; if concluding the Agreement, I grant the consent for the term thereof and the next 3 years after fulfilling my financial obligations under the Agreement if such obligations will cease by fulfilment or in a substitute way to fulfilment, or after termination of the Agreement if financial obligations under the Agreement will cease otherwise.

(vi) An agreement according articles (i) – (v) of this clause is also applied on bank’s product – credit card, that will be issued to co-applicant if conditions defined by bank are fulfilled.

(vii) I hereby confirm that before signing the consents I was informed about my rights related to processing my personal data according to the Act on the protection of personal data. I have also read theInformation Memorandum, which contains a notice of my rights in relation to processing my personal data within BCIR and for the purposes of mutual provision of information among users of BCIR and/or NCIR, provided that the current wording of the Information Memorandum is available anytime at www.rb.cz or at the branch offices of Raiffeisenbank a.s.

I hereby undertake to provide cooperation in presenting other documents required by the bank. I represent that as of the time of submitting the application an execution on my property was neither adjudicated nor performed. Furthermore, I represent that the above information is true and accurate and that I do not keep secret any facts, which could affect an appreciation of this application. I undertake to inform Raiffeisenbank a.s. about any change thereof without undue delay. I also agree with preparing business and services offers and with sending such offers.

In / on

Signature of the co-applicant Signature of the co-applicant

Signature of the application:

I represent that I am not a person with special relationship to the bank I am a person with special relationship to the bank.

In / on

Signature of the co-applicant Signature of the co-applicant

Identification of physical entities – co-applicants (according to a proof of identity):
Type of document / ID card passport / ID card passport
Document number
Issued by
Valid until
Issued on

I represent that I have verified the information sated in the application against the proof of identity and the information COMPLIES / DOES NOT COMPLY 1) with data stated in the above verified proof of identity. 1) strike out the inapplicable option.

NON-COMPLIANT data: …………………………………………………………………………………………………………………………………………..

In / on

Name of the identifying person His / her signature

Application for a mortgage loan, enclosure – co-applicant, 081201 Page 3 of 3