A Application for Permit of Entry/Drive in

to the Premises of Liberty Ostrava a.s.

Provider

Liberty Ostrava a.s., Ident. no.: 451 93 258, Vratimovska 689, 707 02 Ostrava-Kuncice.

Applicant’s data

Applicant is a company, which has direct contractual relation with Liberty Ostrava a.s. or direct contractual relation with company having its headquarters in the Premises of Liberty Ostrava a.s.

Company name (as per Business Register or Trades Register)	Ident. no.:
Headquarters (as per Business Register) or registered place of business (as per Trades Register)	VAT no.:
Postal address (if different from the headquarters or the registered place of business)
Surname and first name of the applicant’s contact person	Tel. no.
E-mail

Justification of application

Contractual partner (please select only 1 option)	Area company of Liberty Group
Liberty Ostrava a.s.	A:	Main Premises
Maxion Wheels Czech s.r.o.	Ř:	Headquarters of Liberty Ostrava a.s.
VITKOVICE HEAVY MACHINERY a.s.	DV:	Mine supports and road crash barriers
MG Odra Gas, spol. s r.o.	G:	Road transport (garages)
H:	Slag management (dump yard)
FM:	Office building in Frýdek-Místek

Contractual relation	Contract no.
Other reason	Specification:

Required validity period:	Valid from	Valid until

Applicant’s statement

Authorized representative of Applicant hereby affirms that data given in this Application are true (incl. its annexes) and bears responsibility for instructing persons about the Basic rules valid for Entry and stay of persons in the Premises of Liberty Ostrava a.s.

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

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

Surname and first name of the authorized representative of the Provider	Drive-in free of charge Stamp and signature	Paid drive-in Stamp and signature
Tel. no.	Date

Statement of the Protection & Internal Administration dept.

A: Application for Permit of Entry/Drive in to the Premises of Liberty Ostrava a.s.

Filling in instructions

Application for Permit of Entry/Drive in to the Premises of Liberty Ostrava a.s. (further referred to only as Application) serves as a basis for issue or activation of electronic chip cards – long-term Entry Permits and long-term Drive in Permits further referred to only as Permits) to the Premises of Liberty Ostrava a.s.

If the Application for Permit of entry of persons and Drive-in of vehicles is based upon concluded contract on providing of services, “Application for Permit of Entry/Drive in to the Premises based on the contract on providing of services” marked B1, B2 and B3 will be used.

Application must be filled in clearly (if possible by PC or in block letters) while mentioning all required data, not forgetting its approval by the Provider and handing over of the Application to the Entry Permit Issue Office within sufficient time in advance (minimum 1 week) before the initial data of the Permit’s validity.

Long-term entry permits bear photo of the person. Based on this fact the Applicant must on his own initiative get the necessary information and agree upon the date of taking the picture at the photo-workplace, which is located at the building of the Entry Permit Issue Office. Permits are never sent by mail and the Applicant must agree upon the date of their taking over.

Chip cards are issued and activated at the workplace of the Entry Permit Issue Office. Contact tel. no.: 595 685 919, 595 686 019, email: povolovanivstupu.ostrava@libertysteelgroup.com.

Applicant’s data

Applicant is a company, which has direct contractual relation with Liberty Ostrava a.s. or direct contractual relation with company having its headquarters in the Premises of Liberty Ostrava a.s.

Company name: accurate company name of the Applicant as stated in the Business Register or in the Trades Register. If physical entity stands for the Applicant, then the surname and the name of the Applicant are to be provided.

Ident. no.: identification no. of the business company of the Applicant.

Headquarters or registered place of business: accurate headquarters of the company as shown in the Business Register, and in case of a freelance person, the registered place of business as shown in the Trades Register. If physical entity stands for the Applicant, then the permanent address must be shown.

VAT no.: tax identification no. of the business company of the Applicant.

Postal address: address used for sending eventual mail. This is to be mentioned solely when being different from the headquarters or the registered place of business, and/or if the headquarters or the registered places of business are incomplete postal addresses.

Surname and first name of the applicant’s contact person: please mention a person, who is authorized and competent for discussions relating to the Entry of persons and drive in of vehicles.

Tel. no.: phone number of the contact person.

E-mail: e-mail address of the contact person. Subsequently lists of valid Permits of Entry/Drive in, lists of passes through and drive through via gatehouses of the Premises etc. are sent to this address upon request.

Justification of application

Contractual partner: only one of the offered options will be chosen for one Application. Liberty Ostrava a.s. means also its subsidiaries with headquarter in the Premises. If services are provided for several contrac-tual partners, it is necessary to fill in the Application for each contractual partner separately.

Area: select one or more of the offered areas where Entry/Drive in permit is required. The area is mentioned only in case of contractual partner of Liberty Ostrava a.s.

Contractual relation: if Applicant concluded contract, then click on Contractual relation and fill in the contract no. If Application for Permit of entry of persons and Drive-in of vehicles is based upon concluded contract on providing of services, then Application marked B1, B2 and B3 is used.

Other reason: if Application results from other than contractual relation, please mark “Other reason“ and provide details in the specification.

Required validity period: please mention the initial and the final date of validity of the required Permits (within maximum extent of the concluded contract).

Applicant’s statement

Authorized representative of Applicant confirms that data of the Application are true (including data given in its annexes) and bears responsibility for instructing of the persons mentioned in the Application with the Basic rules for Entry and stay of persons in the Premises of Liberty Ostrava a.s.

Approval of the application by Provider

Applicant shall secure approval of Application by responsible person of Liberty Ostrava a.s., and/or from company having its headquarters in the Premises of Liberty Ostrava a.s.

Annex 1 to the A: Application for Permit of Entry/Drive in to the Premises of Liberty Ostrava a.s.

Entry of persons

First name	Surname, title	Date of birth	Profession	Signature *
Employer Ident. no.	Remark	Chip card was taken over by

First name	Surname, title	Date of birth	Profession	Signature *
Employer Ident. no.	Remark	Chip card was taken over by

First name	Surname, title	Date of birth	Profession	Signature *
Employer Ident. no.	Remark	Chip card was taken over by

First name	Surname, title	Date of birth	Profession	Signature *
Employer Ident. no.	Remark	Chip card was taken over by

First name	Surname, title	Date of birth	Profession	Signature *
Employer Ident. no.	Remark	Chip card was taken over by

First name	Surname, title	Date of birth	Profession	Signature *
Employer Ident. no.	Remark	Chip card was taken over by

First name	Surname, title	Date of birth	Profession	Signature *
Employer Ident. no.	Remark	Chip card was taken over by

First name	Surname, title	Date of birth	Profession	Signature *
Employer Ident. no.	Remark	Chip card was taken over by

First name	Surname, title	Date of birth	Profession	Signature *
Employer Ident. no.	Remark	Chip card was taken over by

First name	Surname, title	Date of birth	Profession	Signature *
Employer Ident. no.	Remark	Chip card was taken over by

* I confirm with my signature that I have made myself acquainted and will adhere to the Basic Rules for Entry and Stay of Persons in 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.

Applicant’s statement

Stamp and signature of the responsible representative of the Applicant

Annex 1 to the A: Application for Permit of Entry/Drive in to the Premises of Liberty Ostrava a.s.

Entry of persons – Filling in instructions

List of persons for which the Applicant requires issue or activation of chip cards – Entry Permit to the Premises of Liberty Ostrava a.s. It is part of the Application for Permit of Entry/Drive in to the Premises of Liberty Ostrava a.s.

Profession: profession which the person will carry out in the Premises of Liberty Ostrava a.s.

Signature: signature of the person for which the long-term permit is required.

Employer Ident. no.: identification no. of the business company with which the person concluded work contract (work agreement, contract on providing services), and/or identification no. of a freelance person if the service is provided based on Business authorization document. This is not filled out if the identification no. of the employer is identical with the identification no. of the Applicant.

For each mentioned identification no. of the employer it is necessary to fill in annex no. 3 of the Application - data on subcontractor.

Chip card was taken over by: Mention date of taking over of the issued chip card and signature of the person, who takes the card over.

Applicant’s statement

Authorized representative of the Applicant confirms that data are correct and also bears responsibility for informing the mentioned persons about the basic rules valid for entry and stay of persons in the Premises of Liberty Ostrava a.s.

Annex 2 to the A: Application for Permit of Entry/Drive in to the Premises of Liberty Ostrava a.s.

Vehicles Driving-in

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Chip card was taken over by
Ident. no. of user	Valid from	Valid until	Short-term drive in	Remark

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Chip card was taken over by
Ident. no. of user	Valid from	Valid until	Short-term drive in	Remark

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Chip card was taken over by
Ident. no. of user	Valid from	Valid until	Short-term drive in	Remark

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Chip card was taken over by
Ident. no. of user	Valid from	Valid until	Short-term drive in	Remark

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Chip card was taken over by
Ident. no. of user	Valid from	Valid until	Short-term drive in	Remark

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Chip card was taken over by
Ident. no. of user	Valid from	Valid until	Short-term drive in	Remark

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Chip card was taken over by
Ident. no. of user	Valid from	Valid until	Short-term drive in	Remark

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Chip card was taken over by
Ident. no. of user	Valid from	Valid until	Short-term drive in	Remark

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Chip card was taken over by
Ident. no. of user	Valid from	Valid until	Short-term drive in	Remark

Vehicle license plate	Type of vehicle	Vehicle make and model	Category	Chip card was taken over by
Ident. no. of user	Valid from	Valid until	Short-term drive in	Remark

Applicant’s statement

Stamp and signature of the responsible representative of the Applicant

Annex 2 to the A: Application for Permit of Entry/Drive in to the Premises of Liberty Ostrava a.s.

Vehicles Driving-in – Filling in instructions

List of vehicles, for which Applicant requests issue or activation of chip cards – Drive in Permits to the Premises of Liberty Ostrava a.s. It is part of the Application for Permit of Entry/Drive in to the Premises of Liberty Ostrava a.s.

Conditions of drive in shall be determined by Provider as per valid regulations/directives.

For the purpose of drive in a vehicle is a single-track motor vehicle with license plate or a two-track motor vehicle.

Usage of traffic routes in the Premises by road motor vehicles (unless specified otherwise) is subject to settlement of contractual sum depending on the category of the vehicle and the Permit’s validity. Three issues of short-term permit in of the total duration of 7 days of the given calendar month are Permitted free of charge.

Vehicles driving in to the Premises are divided into 3 categories with variable monthly settlements:

Highest permissible weight	Category	Monthly rate, VAT incl.
below 3.5 t	I	CZK 500.00
3.5 – 10 t	II	CZK 600.00
above 10 t	III	CZK 900.00

One month is understood as given calendar month, and/or its equivalent, e.g. duration of 30 days. The lowest unit is rate per 1 month. If duration exceeding 1 month is requested, then the settlement is rounded upwards to the entire multiples of monthly rates.

Motor vehicle license: license plate, and/or state number plate of the vehicle as per the technical registration papers of the vehicle. In case of vehicles, which do not have this license plate, please provide registration no. of this vehicle.

Type of vehicle: please provide type of vehicle as given in the table (according to the technical registration papers of the vehicle)

O	Personal	N	Truck	T	Tractor	P	Working machine
A	Bus	S	Special	M	Motorcycle	X	Others

Vehicle make and model: brand name and vehicle model as per registration papers of the vehicle (for instance Skoda Octavia, Ford Focus, Volkswagen Passat etc.)

Category: vehicle category is to be mentioned here based on the highest permitted weight as given in technical registration papers of the vehicle as given in the above shown table (vehicle up to 3.5 tons = category I etc.)

Chip card was taken over by: Mention date of taking over of the issued chip card and signature of the person, who takes the card over.

Ident. no. of user: identification no. of the business company, which uses the vehicle for securing of its activities in the Premises. Please do not fill in if the identification no. of User is identical with the identification no. of Applicant.

Valid from, Valid until: initial and final date of the Drive in Permit validity. Period, during which Permit of Drive in for the given vehicle is indispensable, is mentioned here. Period does not need to be mentioned here if it is identical with the requested period of validity as mentioned on the first page of the Application.

Short-term entry: please fill in YES, if issue of long-term Drive in Permit is not requested.

Applicant’s statement

Authorized representative of the Applicant confirms that data are correct.

Annex 3 to the A: Application for Permit of Entry/Drive in to the Premises of Liberty Ostrava a.s.

To be filled in for every company, whose ident. no. is shown in the list of persons in annex no. 1 – Entry of persons or in annex no. 2 – Vehicles Driving-in.

Subcontractor’s data

Company name (as per Business Register or Trades Register)	Ident. no.:
Headquarters (as per Business Register) or registered place of business (as per Trades Register)	VAT no.:
Postal address (if different from the headquarters or the registered place of business)
Surname and first name of the subcontractor’s contact person	Tel. no.
E-mail

Subcontractor’s data

Company name (as per Business Register or Trades Register)	Ident. no.:
Headquarters (as per Business Register) or registered place of business (as per Trades Register)	VAT no.:
Postal address (if different from the headquarters or the registered place of business)
Surname and first name of the subcontractor’s contact person	Tel. no.
E-mail

Subcontractor’s data

Company name (as per Business Register or Trades Register)	Ident. no.:
Headquarters (as per Business Register) or registered place of business (as per Trades Register)	VAT no.:
Postal address (if different from the headquarters or the registered place of business)
Surname and first name of the subcontractor’s contact person	Tel. no.
E-mail

Subcontractor’s data

Company name (as per Business Register or Trades Register)	Ident. no.:
Headquarters (as per Business Register) or registered place of business (as per Trades Register)	VAT no.:
Postal address (if different from the headquarters or the registered place of business)
Surname and first name of the subcontractor’s contact person	Tel. no.
E-mail

Applicant’s statement

Stamp and signature of the responsible representative of the Applicant

Annex 3 to the A: Application for Permit of Entry/Drive in to the Premises of Liberty Ostrava a.s.

Subcontractor’s data – Filling in instructions

Data on the subcontractors of the Applicant. This annex is filled for each company, the identification no. of which is shown in annex no. 1 Entry of persons or in annex no. 2 – Vehicles Driving-in. It is part of the Entry/Drive in to the Premises of Liberty Ostrava a.s.

Company name: accurate company name of the Subcontractor as stated in the Business Register or in the Trades Register. If physical entity stands for the Subcontractor, then the surname and the name of the Subcontractor are to be provided.

Ident. no.: identification no. of the business company of the Subcontractor.

Headquarters or registered place of business: accurate headquarters of the company as shown in the Business Register, and in case of a freelance person, the registered place of business as shown in the Trades Register. If physical entity stands for the Applicant, then the permanent address must be shown.

VAT no.: tax identification no. of the business company of the Subcontractor.

Postal address: address used for sending eventual mail. This is to be mentioned solely when being different from the headquarters or the registered place of business, and/or if the headquarters or the registered places of business are incomplete postal addresses.

Surname and first name of the subcontractor’s contact person: please mention a person, who is authorized and competent for discussions relating to the Entry of persons and drive in of vehicles.

Tel. no.: phone number of the contact person.

E-mail: e-mail address of the contact person. Subsequently lists of valid Permits of Entry/Drive in, lists of passes through and drive through via gatehouses of the Premises etc. are sent to this address upon request.

Applicant’s statement

Authorized representative of the Applicant confirms that data are correct.

Basic rules

For Persons Staying on the Premises & Entering the Premises
of Liberty Ostrava

H&S Rules, Rules for Healthy Return Home

For the sake of your personal safety, we hereby draw your attention to the fact that the premises of Liberty Ostrava a. s. (thereinafter referred to as the Premises) ranked – from the viewpoint of safety and health protection – among particularly hazardous Premises.

Each person entering the Premises shall be liable for adherence to internal safety regulations concerning entering / driving-in the Premises and persons´ movement on the Premises that they have been made acquainted with.

Hazards of

▪ falling-down and slipping	PPE: suitable safety boots

▪ falling from the heights	PPE: harness with securing device, step ladder, foot rest

▪ objects falling	PPE: safety helmet/hat with a chinstrap

▪ striking / hitting	PPE: safety helmet/hat with a chinstrap

▪ noisiness	PPE: ear protection

▪ eyes affection	PPE: safety goggles (protecting against solids, spatter of liquids or hot metal)

▪ abrasion, contamination	PPE: working clothes/overall, suitable work gloves and work shoes protecting the limbs

▪ pressing	PPE: working clothes with reflex strips or a warning vest, risk cause by cranes and lifted/hoisted loads, by mechanisms – excavators, bulldozers, high-lift trucks, road and rail vehicles

▪ winding-up and drawing-in	PPE: properly tight working clothes/overall, risks caused by revolving mechanisms or belt conveyors

▪ other hazards	electrical accident, burns, scald, acid burn, radiation exposure, serious accidents, intoxication, suffocation

Ten Safety Basic Rules

1	I use marked roads and access paths only (primarily I do not enter rail-yard)

2	I do not enter any hazardous and restricted places

3	I do not stay under suspended loads

4	I do not handle control units of machinery and technology

5	I do not touch any electrical cables and hoses

6	I do not remove any damage protective devices (covers)

7	I adhere to safety symbols and safety colours

8	I wear Personal Protective Equipment (PPE)

9	I do not step on stocked material and objects stored in the workplaces (instable positions)

10	I adhere to no smoking on the whole Company premises and in vehicles. No smoking does also relate to smoking of electronic cigarettes.

HEALTH AND SAFETY ARE OUR PRIORITIES. YOUR HEALTH IS YOUR PRIORITY.

First Aid:	155	Company dispatching:	595 687 333

Fire brigade:	150	Entry Permit Issue Office:	595 685 919

Police:	158	Security Supervisory Service:	595 686 216

Basic Duties of entering/driving-in person

▪	To enter/drive-in into the Premises and to stay there with valid entry permit only, i.e. electronic chip card (hereinafter referred to as CC) for a respective person and for a respective vehicle. CC shall be non-transferable one. Such CC shall be valid for a person only whom it has been issued to. It shall be valid with the identity card at the same time. CC of a vehicle shall be valid for a vehicle which it has been issued to.

▪	To enter/drive-in into the Premises and to leave them through watch-houses only within their working hours. Everybody shall identify himself/herself/itself by his/her/its CC, when driving-in by the CC of the vehicle as well, on the CC sensor. CC shall be submitted to gate-keepers in any place on the Premises.

▪	The drivers only are entitled to drive through the watch-house. Fellow-travellers shall walk through turn-stiles.

▪	CC shall be protected from its losing and damaging. As soon as CC validity expires or shall no reason exist for such CC issue, CC shall be put into CC Absorber or it shall be given to the Entry Permit Issue Office. CC non-functionality, changes, loss, reveals and theft shall be immediately report to the Entry Permit Issue Office. Shall CC be lost or damaged, qualified fee must be paid.

▪	While entering/driving-in into the Premises, to list the assets that shall be carried-away/taken-away from the Premises and such list shall confirmed by the gate-keeper. To allow gate-keepers to check luggage including vehicle.

▪	By request of gate-keepers, each person shall be subject to test for drugs and alcohol.

▪	To listen to and to respect instructions and decisions made by gate-keepers and to fairly conduct oneself in face of them.

▪	To consistently observe provisions of Act no. 361/2000 Sb., the Road Traffic Act. Before getting-out of the vehicle it is necessary to engage the brakes in order to prevent the vehicle from moving. Park the vehicle on the designated areas only.

▪	When riding a bicycle it is necessary to use a crash helmet with a chinstrap and a reflex vest.

▪	Adhere to the obligations of the forwarder in accordance with the ADR documentation.

▪	Each road accident on the Premises shall be reported to the Company Dispatching.

▪	Without undue delay, nevertheless, prior to leaving the Premises, report any damaged assets on the Premises and/or own damaged assets to a gate-keeper.

It is forbidden

▪	To enter/drive-in into the Premises intoxicated/impaired and/or to eat/drink alcohol or drugs in any place on the Premises.

▪	To enter/drive-in into the Premises with animals, guns, alcohol or drugs.

▪	On the premises, to move on roller-skates, skate-boards etc.

▪	To take pictures or to film on the Premises without special authorization/permit.

▪	To take away/transfer any assets from the Premises without relevant authorizing documents.

▪	To enter/drive-in into the production shops and bays without consent given by an authorized person of this area or without relevant PPE specified for a given workplace.

▪	To carry out activities in the Premises, which are not directly linked to the fulfilment of work tasks, to stay in the Premises longer than necessary or to stay in such the places, which are not approved and designed for fulfilment of work tasks.

Driver’s Duties During Loading / Unloading

▪	To respect and to adhere to the instructions given by the competent Officer. Not to drive-in to the production shops and bays and to leave them without consent granted by such competent Officer.

▪	Not to move under suspended load. Minimum distance between a person and a load shall be equal to the distance between a load and the floor which a person is standing on.

▪	Do not stay on the loading platform of the vehicle during loading, do not handle crane suspension equipment. Use your own step ladder or any other suitable facility when climbing up to the loading platform of the transport vehicle or when getting down from such a platform and during the vehicle’s canvassing.

▪	Prior to reverse driving commencement, to use horn and during reverse driving, warning turn-signal lights have to be switched ON.

▪	In production shops and bays, engine must be switched OFF except for necessary driving-in and driving-out.

▪	From loading area and from canvas, not to remove residual material, snow, trash etc.

▪	On the weighing bridges to respect priority of weighing of the technological vehicles marked by Liberty Ostrava a.s. logo.

▪	After termination of the loading process to secure (close) device used for clamping and protection of the load (e.g. canvases, doors, ropes, lanyards and others).

▪	Within 15 minutes after driving-in to the Premises, vehicle must be weighted for the first time (tarring).

▪	The loaded vehicle must be weighted within 2 hours since the issue of the latest loading bill.

▪	After the last weighing of the loaded vehicle must leave the Premises within 15 minutes.

Control of the above-given Basic Rules is carried out on the Premises. Violation of these Rules can result in imposing contractual fine, and/or prohibition of subsequent entry/driving-in into the Premises.