Application for permission

of taking pictures/film shooting

in the Premises of Liberty Ostrava

Provider

Liberty Ostrava a.s., Ident. No.: 451 93 258, Vratimovská 689/117, 719 00 Ostrava-Kunčice

Applicant’s data

The Applicant a company being in a contractual relation with Liberty Ostrava a.s. or in a contractual relation with the company residing on the Premises of Liberty Ostrava a.s.

Company name (as per Business Register or Trades Register)
Headquarters (as per Business Register) or registered place of business (as per Trades Register)

Subcontractor’s data

To mention company, which employs persons shown in this Application (and/or freelance person) if being different from the Applicant.

Company name (as per Business Register or Trades Register)
Headquarters (as per Business Register) or registered place of business (as per Trades Register)

Justification of Application

Point of interest
Purpose of taking pictures/film shooting
Taken pictures/film shot shall be made	Required validity date – from	Required validity date – until
public (yes/no):

Approval of the application by Provider (not to be filled in by Applicant)

Set conditions of taking picture/film shooting:
Surname and first name of the authorized representative of the Provider	Stamp and signature
Tel. no.	Date

Applicant’s statement

Authorized representative of the Applicant hereby affirms that data given in this Application are true and at the same time bears responsibility for respecting of the purpose and conditions set in this Application.

Surname and first name of the authorized representative of the Applicant	Stamp and signature
Tel. no.	Date

Statement of the Protection & Internal Administration dept.

Annex to the Application for permission of taking pictures/film shooting in the Premises of Liberty Ostrava a.s.

List of persons

First name	Surname, title	Date of birth	Signature *

First name	Surname, title	Date of birth	Signature *

First name	Surname, title	Date of birth	Signature *

First name	Surname, title	Date of birth	Signature *

First name	Surname, title	Date of birth	Signature *

First name	Surname, title	Date of birth	Signature *

First name	Surname, title	Date of birth	Signature *

First name	Surname, title	Date of birth	Signature *

First name	Surname, title	Date of birth	Signature *

First name	Surname, title	Date of birth	Signature *

First name	Surname, title	Date of birth	Signature *

First name	Surname, title	Date of birth	Signature *

First name	Surname, title	Date of birth	Signature *

First name	Surname, title	Date of birth	Signature *

* I hereby confirm by my signature that I shall read through and observe the Basic rules valid for Entry and stay of person in the Premises of Liberty Ostrava a.s. I also acknowledge that Liberty Ostrava a.s., Company ID 451 93 258 (hereinafter the Controller), as the Controller and FENIX INTERNATIONAL, spol. s r.o. Company ID: 186 30 995 (hereinafter referred to as "the Processor") as the processor are authorized to process the data concerning me ("Data") that are required for the safe entry, transit, movement or proper performance of my activity in the premises of Liberty Ostrava ant to the registration of persons entering these Premises (hereinafter referred to as the "Purpose"). This processing is thus based on these legitimate interests of the Controller. The personal data can be transmitted to third person in the premises in whose interest the entry permit was granted. Processing will take place for the duration of the authorization and for subsequent 3 years. I further declare that I was acquainted with my right of access to the data, the right to rectification, the limitation of the processing, the addition or deletion, and the right to file a complaint with the Office for Personal Data Protection. I hereby confirm that the provided data concerning me are true.