# Regulation (EU) 2019/788 of the European Parliament and of the Council of 17 April 2019 on the European citizens’ initiative, Division: TO BE COMPLETED BY THE SIGNATORIES IN CAPITAL LETTERS:

Extent: E+W+S+N.I.

‘I hereby certify that the information that I have provided in this form is correct and that I have not already supported this initiative.’
German nationals residing outside the country only if they have registered their current permanent residence at their responsible German diplomatic representation abroad.
Signature is not mandatory if the form is submitted online via the central online collection system as referred to in Article 10 of Regulation (EU) 2019/788 or an individual online collection system as referred to in Article 11 of the said Regulation.
FULL FIRST NAMES
FAMILY NAMES
RESIDENCE(street, number, postal code, city, country)
DATE OF BIRTH
DATE
SIGNATURE

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Source: https://www.legislation.gov.uk/eur/2019/788/annex/III/division/1/division/3 (the official version)
Page: https://openlegislation.uk/eu-regulation-2019-788/annex-III/division-1/division-3
Contains public sector information licensed under the Open Government Licence v3.0. Source: legislation.gov.uk, The National Archives.