Regulations

REGULATIONS FOR THE PROVIDING OF SERVICES BY THE MEANS OF THE WWW.RCIN.ORG.PL WEBSITE

TABLE OF CONTENTS:

SUBJECT MATTER OF THE REGULATIONS
DEFINITIONS
GENERAL STATEMENTS (including data identifying service provider - address, e-mail address and telephone number)
SERVICES PROVIDED BY ELECTRONIC MEANS
TERMS AND PROCEDURE FOR AGREEMENT ON THE PROVISION OF SERVICES
OUT-OF-COURT COMPLAINT AND REDRESS PROCEDURES AND RULES OF ACCESS TO THESE PROCEDURES
RIGHT OF WITHDRAWAL. PROCEDURE AND TIMEFRAME FOR THE RIGHT OF WITHDRAWAL
PROVISIONS CONCERNING ENTREPRENEURS
PERSONAL DATA
FINAL PROVISIONS. MODIFICATIONS TO THE TERMS AND CONDITIONS

APPENDIX NO. 1

SUBJECT MATTER OF THE REGULATIONS

1.1 The Regulations define the rights and obligations relating to the use of the website www.rcin.org.pl and rules for the use of services provided by means of the website www.rcin.org.pl.

1.2 The Regulations, to the extent of services provided by electronic means, are the terms and conditions for provision of services by electronic means referred to in Article 8.1.1 of the Act of 18.07.2002 on provision of services by electronic means (i.e. of 6 February 2020, Journal of Laws of 2020, item 344).

DEFINITIONS

2.1 All upper-case terms used in the Regulations shall have the following meaning:

2.1.1. Working Day - every day from Monday to Friday excluding days which are statutory holidays;

2.1.2. Registration Form - Electronic Service, interactive form available on the website https://rcin.org.pl/dlibra/new-account? allowing to open an Account;

2.1.3. Consumer - User who is a natural person, using the website www.rcin.org.pl and entering into an Agreement for the provision of services or an agreement for the provision of Electronic Services with Service Provider for the purpose that is not directly related to his/her economic or professional activity (pursuant to Article 221 of the Civil Code);

2.1.4 Civil Code - the Civil Code Act of 23 April 1964. (i.e. dated 16 May 2019, Journal of Laws of 2019, item 1145);

2.1.5. RCIN Consortium - a Consortium of Scientific Institutes established on the basis of an agreement dated 14/09/2021, the purpose of which is, among others, to maintain, extend and promote the digital resources of the Consortium Partners (Scientific Institutes) on the Digital Repository of Scientific Institutes (RCIN) platform;

2.1.6 Account - a group of resources in the Service Provider's IT system, denoted by an individual name (login) and password provided by the User, in which the data provided by the User are stored; setting up and maintaining an Account within the Service shall be considered an Electronic Service;

2.1.7 RCIN - Digital Repository of Scientific Institutes containing digitized archival materials, scientific publications, research documentation and written cultural heritage selected from collections of the Scientific Institutes (listed on https://rcin.org.pl/dlibra/text?id=institutions) and their libraries;

2.1.8. Terms and Conditions - herewith the terms and conditions for provision of services by means of the www.rcin.org.pl website;

2.1.9. Service - the website available under the domain www.rcin.org.pl;

2.1.10. RCIN Services - the service performed by the Service Provider consisting in making available to the User the RCIN resources collected on the Website, being the subject of the Agreement for provision of services between the User and the Service Provider; making the RCIN resources available within the Website shall be considered an Electronic Service;

2.1.11. Service Provider - the Institute of Mathematics of the Polish Academy of Sciences with its registered office in Warsaw 00-655, at Jana i Jędrzeja Śniadeckich 8, entered into the Register of Scientific Institutes managed by the Polish Academy of Sciences under number: RIN-III-19/98, NIP 5250008867, REGON: 000325860, e-mail address: rcin@impan.pl, telephone number: 22 52 28 191 on behalf of the RCIN Consortium;

2.1.12. Service Agreement - agreement for provision of Services executed or signed between the User and Service Provider via the Website, pursuant to which Service Provider shall provide certain services at the User's request;

2.1.13. Electronic Service - a service provided electronically by the Service Provider to the User by means of the Website;

2.1.14 Consumer Rights Act - the Consumer Rights Act of 30 May 2014 (i.e. 28 January 2020, Journal of Laws of 2020, item 287 as amended);

2.1.15. User - a natural person with full legal capacity, and in cases provided for by generally applicable regulations also a natural person with limited legal capacity, a legal person or an organizational unit without legal personality to which the Act grants legal capacity, which has entered or intends to enter into a Service Agreement with the Service Provider.

GENERAL STATEMENTS (including data identifying service provider - address, e-mail address and telephone number)

3.1.The Website available under domain www.rcin.org.pl is operated by the RCIN Consortium represented by the Institute of Mathematics of the Polish Academy of Sciences with its seat in Warsaw 00-655, at ul. Jana i Jędrzeja Śniadeckich 8, registered in the Register of Scientific Institutes managed by the Polish Academy of Sciences under no: RIN-III-19/98, NIP 5250008867, REGON: 000325860, e-mail address: rcin@impan.pl, phone number: 22 52 28 191 on behalf of the RCIN Consortium.

3.2.Acceptance of these Terms and Conditions is voluntary, however without accepting the Terms and Conditions it is not possible to use the Website and conclude a Service Agreement.

3.3.These Regulations are addressed to both Consumers and entrepreneurs using the Service, unless a given provision of the Regulations states otherwise and is addressed exclusively to Consumers or Users being entrepreneurs.

SERVICES PROVIDED BY ELECTRONIC MEANS

4.1. The Service Provider shall provide the following Electronic Services to the Users by means of the Website:

4.1.1. providing Users with an Account on the Website;

4.1.2. providing Users with a possibility to search, browse, download or temporarily use RCIN resources.

4.2. The Service Provider commits to provide the Electronic Services referred to in section 4.1 on the terms and to the extent specified in the Terms and Conditions.

[ Account]

4.3. The User may set up an individual Account on the Website by performing the following steps: (1) completing the Registration Form, (2) accepting the Terms and Conditions, and (3) clicking on the "Register" box. In order to open an Account, it is necessary to provide in the Registration Form the User's name, User's email address and the password.

4.4. In case of a User who is not a Consumer, creating an Account can be done only by a person who is authorized to perform actions related to creating an Account on the Website and use of services available on the Website.

4.5. Creation of an Account is not required in order to use the RCIN Service. Creating and using an Account is voluntary and free of charge.

4.6. An Account shall enable:

4.6.1. create own list of favorite items;

4.6.2. export the list to a file;

4.6.3. subscribe to a list of items newly added to the Repository on a daily or weekly basis.

4.7. An Agreement for the provision of services consisting in the creation and maintenance of an Account shall be concluded when the User completes the Registration Form and clicks the "Register" button.

4.8. The Electronic Service of creating and maintaining an Account is provided free of charge for an indefinite period of time.

4.9. The User may at any time and without giving any reason terminate the Agreement for the provision of services consisting in creating and maintaining an Account by submitting an appropriate request to the Service Provider via email to the address: rcin.org.pl@gmail.com. The User's request should include the email address provided by the User in the Registration Form when creating an Account.

4.10. Creating an Account does not guarantee access to all objects available in the RCIN resources. Some objects are not generally accessible due to copyright protection. Individual objects in RCIN resources may be accessible only from computers located in particular scientific institute, co-creating RCIN. In this case creating an Account and logging in shall not cause that particular object will be available through the Service. Possible way of access to particular objects from RCIN resources is described in description elements: "Rights" and "Rules of use".

[RCIN Service]

4.11. Through the Service, the User, at his/her preference, may search for and view and download objects contained in RCIN resources.

4.12. RCIN resources include objects of various types, in particular books, magazines, directories, maps, scientific data and audiovisual resources presented in various formats.

4.13. The conclusion of the agreement for the provision of RCIN Services results from actions taken each time by the User within the framework of using the Website and occurs respectively at the moment of:

4.13.1. beginning to search for objects in the RCIN resources;

4.13.2. beginning to browse through the RCIN resources

4.13.3. commencement of downloading of objects in the RCIN resources.

4.14. Acceptance by the User of any action taken by him/her within the scope of using RCIN Services (in particular by using the context search engine, clicking fields such as "Advanced Search", "Search Collection", "Show Content", "Download") shall constitute the User's declaration of will submitted via the Website and aimed directly at concluding the Agreement for the provision of RCIN Services with the Service Provider.

4.15. Use of RCIN Services does not require creation and use of an Account.

4.16. RCIN Services shall be provided free of charge and shall be voluntary, one-time in nature and shall terminate respectively at the moment of:

4.16.1. termination of use of the Service;

4.16.2. completion of searching or browsing through the RCIN resources;

4.16.3. download of an object in the RCIN resources.

4.17. The Agreement for the provision of RCIN Services shall be performed in full by the Service Provider at the moment of the User's use of a given RCIN Service, to which the User agrees. The User who is a Consumer, after the Service Provider has performed the RCIN Service, loses the right to withdraw from the Agreement for the provision of RCIN Services.

4.18. Objects contained in RCIN resources are protected by copyright. The scope and rules for the use of particular objects from the RCIN resources by the Users shall depend, in particular, on the type of license granted by the author of a given work contained in RCIN resources.

4.19. Detailed information on the possible ways to access and rules of use for particular objects in RCIN resources is contained in the elements of the description of the respective object: "Rights" and "Rules of Use".

4.20. Some objects from RCIN's resources are available to Users via the Website under open, free of charge Creative Commons licenses. The type of license and terms of use for such objects in RCIN's resources shall be specified each time in the description of a given object. More information about Creative Commons licenses can be found here: https://creativecommons.pl/.Detailed information about individual Creative Commons licenses can be found here: https://creativecommons.pl/poznaj-licencje-creative-commons/.

4.21. Some of the objects in RCIN's resources may be used by Users through the Service under fair use. Detailed rules of using such objects from the RCIN resources within the framework of fair personal use shall be defined in each description of a given object.

4.22. Access to some objects from RCIN resources may be restricted and using them may be allowed only on terminals of particular scientific institute. Detailed rules for the use of such objects within the RCIN resources within the framework of permitted personal use are defined each time in the description of a given object.

4.23. If an object in the RCIN resources belongs to the public domain and is therefore excluded from copyright protection, this shall be specified in each individual object description. With respect to objects in the public domain, use shall be allowed without restrictions under copyright law.

4.24. The User shall be obliged to use particular objects included in the RCIN resources in accordance with the rules under which the objects are made available (defined each time in the description of a particular object). In particular with respect to objects in the RCIN resources that are made available under a license, the User shall be obliged to follow the rules of that license.

4.25. The User shall be obliged to use RCIN objects in a manner consistent with applicable law, the provisions of the Rules and Regulations, as well as accepted customs and rules of social coexistence and good manners, taking into account respect for personal rights and copyrights and intellectual property of the Service Provider and third parties.

[Procedure for complaints]

4.26. Complaints related to the provision of Electronic Services by the Service Provider and other complaints related to the Services available on the Site may be submitted by the User in particular:

4.26.1. in writing to the address: Institute of Mathematics of the Polish Academy of Sciences, RCIN Consortium, 00-656 Warsaw, Jana i Jędrzeja Śniadeckich 8;

4.26.2. in electronic form via e-mail to the address: rcin.org.pl@gmail.com.

4.27. In order to expedite and facilitate the processing of the complaint, please indicate in the description of the complaint (1) information and circumstances regarding the subject matter of the complaint, in particular the type and date of occurrence of the irregularity, (2) the User's request and (3) the email address indicated by the User in connection with the use of the Service (4) contact details of the User submitting the complaint. The requirements given in the previous sentence are only in the form of a recommendation and do not affect the effectiveness of complaints submitted without the recommended description of the complaint.

4.28. The Service Provider shall consider the complaint and inform about the result of its consideration immediately, no later than within 14 (fourteen) calendar days from the date of its submission. If the data or information provided in the complaints would require supplementation, the Service Provider shall request the User to supplement them before considering the complaint, but the Service Provider is obliged to respond to the Consumer on the complaint within a maximum of 30 days from receipt. The response to the claim shall be provided by the Service Provider to the Consumer in the form of an email to the email address provided by the Consumer.

[Technical Requirements]

4.29. The basic technical requirements to be met in order to work with the tele-information system used by the Service Provider, including the use of the Site and conclusion of the Service Agreement is to have a computer or other device connected to the Internet, equipped with an Internet browser: Mozilla Firefox version 17.0 and above or Internet Explorer version 10.0 and above, Opera version 12.0 and higher, Google Chrome version 23.0. and above, Safari version 5.0 and above, Microsoft Edge version 25.10586.0.0 and above and access to electronic mail, as well as enabling in the web browser the possibility of saving cookies and JavaScript support. Service provider recommends a minimum screen resolution of 1024x768.

[Prohibition of unlawful content]

4.30. The User is obliged to use the Site, including the offered Electronic Services, in a manner compliant with the provisions of applicable law, provisions of these Terms of Use, as well as with the accepted custom and rules of social coexistence and good practice, with respect to personal rights and copyrights and intellectual property of the Service Provider and third parties. The User is obliged to enter data consistent with the facts. The User is obliged not to provide illegal content.

TERMS AND PROCEDURE FOR AGREEMENT ON THE PROVISION OF SERVICES

5.1. The conclusion of the Service Agreement between the User and Service Provider takes place at the moment of commencing a given action by the User within the scope of using the Service.

5.2. Services available within the Service are provided free of charge. No fees shall be charged for the set-up and maintenance of an Account as well as for the provision of RCIN Services (consisting of searching, browsing and downloading objects from RCIN resources).

5.3. The content of the Agreement for the provision of services shall be recorded, secured and made available to the User by means of: (1) publishing these Regulations on the Website and (2) enabling the User to download these Regulations in pdf format. The content of the Service Agreement is additionally stored and secured in the Service IT system.

OUT-OF-COURT COMPLAINT AND REDRESS PROCEDURES AND RULES OF ACCESS TO THESE PROCEDURES

6.1. Detailed information on the possibility of using by the User who is a Consumer the out-of-court ways of dealing with complaints and claims and the rules of access to these procedures are available on the website of the Office of Competition and Consumer Protection at https://uokik.gov./pozasadowe_rozwiazywanie_sporow_konsumenckich.php.

6.2. There is also a contact point at the Chairman of the Office of Competition and Consumer Protection (phone: 22 55 60 333, e-mail: kontakt.adr@uokik.gov.pl or address in writing: Pl. Powstańców Warszawy 1, 00-030 Warsaw.), whose task is to provide assistance to consumers in matters relating to out-of-court resolution of consumer disputes.

6.3. The consumer has the following examples of out-of-court methods of dealing with complaints and claims: (1) an application for dispute resolution to a permanent amicable consumer court (for more information, see: http://www.spsk.wiih.org.pl/); (2) an application for out-of-court dispute resolution to the voivodship inspector of the Commercial Inspection (for more information, see the website of the inspector competent for the place of business of the Service Provider); and (3) the assistance of a county (municipal) consumer ombudsman or a social organization whose statutory tasks include consumer protection (such as the Consumer Federation, the Polish Consumer Association). Advice is provided, i. a. by e-mail at porady@dlakonsumentow.pl and at the consumer helpline number 801 440 220 (open on Working Days, from 8:00 a.m. to 6:00 p.m., call charge as per operator's tariff).

6.4. In accordance with Regulation (EU) No 524/2013 of the European Parliament and of the Council of 21 May 2013 on online dispute resolution for consumer disputes, the Consumer may submit a complaint via the ODR platform at http://ec.europa.eu/consumers/odr. The ODR platform is a web-based consumer and business dispute resolution platform at EU level, which is an interactive and multilingual website with a single point of contact for consumers and entrepreneurs seeking out-of-court resolution of a dispute concerning contractual obligations arising from an online sales or service contract.

RIGHT OF WITHDRAWAL. PROCEDURE AND TIMEFRAME FOR THE RIGHT OF WITHDRAWAL

7.1. A consumer who has entered into a remote agreement, may withdraw from it within 14 calendar days without giving any reason at no cost other than those provided by law. The remote agreement is understood herein as an agreement concluded with the Consumer within an organized system of contract conclusion at a distance, without the simultaneous physical presence of the parties, with the exclusive use of one or more means of remote communication until the conclusion of the agreement inclusive. To meet the deadline it is sufficient to send a statement of withdrawal from the agreement before its expiry. A declaration of withdrawal from the agreement may be submitted, in particular:

7.1.1. in writing to the address: Institute of Mathematics of the Polish Academy of Sciences, RCIN Consortium, 00-656 Warsaw, Jana i Jędrzeja Śniadeckich 8;

7.1.2. in electronic form via e-mail to the following address: rcin.org.pl@gmail.com.

7.2. The declaration may be submitted using the model withdrawal form included as Attachment No. 2 to the Consumer Rights Act, as well as on the model form which constitutes Attachment No. 1 to these Regulations. The Consumer may use the model form, but it is not compulsory.

7.3. The period for withdrawal from the contract starts from the date of conclusion of the agreement.

7.4. The right of withdrawal from the contract concluded at a distance does not apply to the Consumer in relation to contracts for the provision of services, if the Service Provider has performed the service in full with the explicit consent of the Consumer, who was informed before the provision of services, that after the performance by the Service Provider will lose the right to withdraw from the contract.

PROVISIONS CONCERNING ENTREPRENEURS

8.1. This section of the Regulations and the provisions herein only concern Users who are not Consumers.

8.2. The Service Provider shall have the right to withdraw from the Service Agreement with the User who is not a Consumer within 14 calendar days from the date of its conclusion. The withdrawal from the Service Agreement in this case may be without giving any reason and does not give rise to any claims against the Service Provider by the User who is not a Consumer.

8.3. In the case of Users who are not Consumers, the Service Provider may terminate the Agreement for provision of Electronic Services with immediate effect and without stating reasons by sending an appropriate statement to the User.

8.4. Any disputes arising between the Service Provider and the User who is not a Consumer shall be submitted to the court competent for the seat of the Service Provider.

PERSONAL DATA

9.1. The administrator of Users' personal data processed for the purpose of using Electronic Services by means of the Service, as well as for contact, archiving and complaint purposes, and for the purpose of maintaining an Account on the Service, is the RCIN Consortium on behalf of which acts the Mathematical Institute of the Polish Academy of Sciences with its seat in Warsaw 00-655, at Jana i Jędrzeja Śniadeckich 8, entered in the Register of Scientific Institutes kept by the Polish Academy of Sciences under no.: RIN-III-19/98, NIP 5250008867, REGON: 000325860, e-mail address: rcin@impan.pl, phone number: 22 52 28 191 (hereinafter: Administrator).

9.2. The Administrator shall ensure the implementation of the requirements under Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data and repealing Directive 95/46/EC (General Data Protection Regulation) (hereinafter: "GDPR").

9.3. Contact with the Administrator is possible:

9.3.1. by letter to the address: Institute of Mathematics of the Polish Academy of Sciences, RCIN Consortium, 00-656 Warsaw, Jana i Jędrzeja Śniadeckich 8 or

9.3.2. electronically at the e-mail address: rcin@impan.pl or

9.3.3. by phone at: 22 52 28 191.

9.4. The Administrator appointed a Data Protection Officer whom the User may contact in all matters concerning personal data protection. The contact with the data protection officer is possible in writing to the address of the DPO, ul. Śniadeckich 8, 00-656 Warszawa or electronically to the e-mail address iod@impan.pl or by phone to the number 600-996-438.

9.5. Personal data of the User shall be processed in order to:

9.5.1. to conclude a Service Agreement between the User and the Administrator and to perform this agreement - on the basis of Article 6.1.b of the GDPR, i.e. the processing is necessary for the conclusion and performance of the agreement (the subject of which is the performance of the services provided by the Administrator) to which the User is a party or to take action at the request of the User prior to the conclusion of the agreement;

9.5.2. determining or pursuing claims or the defense against claims between the User and the Administrator - on the basis of Article 6(1)(f) GDPR, i.e. on the basis of a legitimate interest pursued by the Administrator, which is the possibility to determine and pursue claims and to defend against claims.

9.6. Providing personal data is voluntary, however, providing data indicated as necessary is necessary to conclude and perform an agreement with the Administrator (failure to provide such data will result in lack of possibility to conclude and perform the agreement with the Administrator).

9.7. The Users' personal data will not be subject to automated decisions, including those from profiling.

9.8. The Users' personal data will be processed for the period necessary for the purposes for which the data are processed (see 9.5) or until they lodge an objection (if the processing is based on the Administrator's lawful interest) - depending on which of these events occurs first. Afterwards, the Administrator will store the data until the statute of limitations for any possible claims and for a period of two (2) months after the end of such applicable limitation period.

9.9. Users' personal data will be disclosed to the following entities: Administrator's employees and associates, IT service providers, hosting providers, consulting, legal services.

9.10. Users' personal data can be made available to entities and authorities authorized to process such data on the basis of legal regulations.

9.11 The Administrator does not intend to transfer the Users' personal data to a country outside the European Economic Area or to an international organization.

9.12. The User shall have:

9.12.1. the right to access their personal data;

9.12.2. the right to request their rectification;

9.12.3. the right to request their deletion;

9.12.4. the right to request limitation of their processing;

9.12.5. the right to data portability, i.e. to receive personal data from the Administrator in a structured, commonly used and machine-readable format. The User may also request the Controller to send his/her personal data that he/she has provided to another controller;

9.12.6. To the extent that the basis for the processing of personal data is the premise of the legitimate interest of the Administrator, the User shall have the right to object to the processing of personal data.

9.13. In order to exercise the above rights, the User shall contact the Administrator using the contact data indicated above (contact data indicated above in clauses 9.3 and 9.4).

9.14. Furthermore, the User has the right to lodge a complaint to the supervisory authority dealing with personal data protection (the President of the Office for Personal Data Protection), if the User believes that the processing of data violates the GDPR. Information on how to file such a complaint can be found here: https://uodo.gov.pl/pl/83/155.

9.15. The Administrator uses and manages cookies on the terms described in the Privacy Policy.

9.16. All other matters relating to the protection of personal data are contained in the Privacy Policy.

10. FINAL PROVISIONS. MODIFICATIONS TO THE TERMS AND CONDITIONS

10.1. Contracts for the provision of services are concluded in Polish or English.

10.2. The Regulations in their current version shall be valid from 01.03.2021.

10.3. The Service Provider reserves the right to change the Terms and Conditions in case of occurrence of at least one of the following important reasons (the catalog of reasons is closed):

10.3.1. a change in the provisions of law affecting the mutual rights and obligations set out in the Contract for the provision of services;

10.3.2. the necessity to adjust the Service Provider's activity to the orders, rulings, provisions or guidelines issued by the relevant authority;

10.3.3. change in the provision of services by electronic means due to technical or technological reasons;

10.3.4. change in the scope or principles of provision of services provided by electronic means by introducing new, changing or withdrawing existing functionalities or services offered to the User;

10.3.5. change of data identifying the Service Provider in the Regulations;

10.3.6. changes in the methods of providing services by the Service Provider - to the extent in which these changes affect the implementation of the provisions of these Regulations;

10.3.7. change of the conditions of using the Service, which shall not worsen the situation of the Users in comparison to the previous conditions.

10.4 The Service Provider shall inform the Users about the change of the Regulations at least 30 days in advance by making the uniform text of the Regulations available on the Site.

10.5 In case of conclusion of continuous agreements on the basis of the Regulations (e.g. provision of Electronic Service - Account), the amended Regulations shall be binding upon the User, if he has been correctly notified (in accordance with the content of the Regulations in force) about the changes and has not terminated the concluded agreement within 30 calendar days from the date of notification.

10.6 The change of Regulations shall not affect the content and conditions of Contracts for the provision of services concluded by the User and the Service Provider before the change of Regulations.

10.7 The Regulations are available to the Users free of charge on the Site and in the Service Provider's office at any time. Users may at any time on the Site review the Regulations, download them and make a printout of the Regulations.

10.8 In matters not regulated herein, generally applicable provisions of Polish law shall apply. The choice of Polish law shall not deprive the Consumer of protection granted to him/her on the basis of provisions that cannot be excluded by agreement.

APPENDIX NO. 1

Withdrawal form

(This form must be completed and returned only in the case of agreement withdrawal)

Addressee:

Institute of Mathematics of the Polish Academy of Sciences, RCIN Consortium

Jana i Jędrzeja Śniadeckich 8, 00-655 Warszawa

rcin@impan.pl

/We(*) hereby inform/inform(*) of my/our withdrawal from the agreement for the provision of the following service: (...).
Date of conclusion of the agreement
First and last name of consumer(s)
Address of consumer(s)
e-mail address given by consumer(s) in relation to the use of the website under the domain www.rcin.org.pl
Signature of consumer(s) (only if this form is sent on paper)
Date

(*) Delete if not relevant.