Attachment B 2 to Specimen 4
Attachment to the list of candidates ..... x) for the European Parliament elections
held in ..... (date)
Declaration of candidate who is a citizen of another European Union member state
"I, the undersigned ...............................................................
name (names) and surname
listed as a candidate for the European Parliament elections hereby declare to have
accepted my candidacy, to be aware of no obstacles to my election or to remove such
obstacles before the European Parliament election day, to have not consented to be
placed at another candidate list for the European Parliament elections
in the country where I live or in another country. I declare that my right
to be elected has not been withdrawn, by a court or administrative decision,
in the country I am a citizen of."
........................... ......................................
Date and place of birth Address of permanent residence or
residence xx) in the Czech Republic
...................................................................................
My last address in the member state I am a citizen of
In ........... on .............. .................................
Candidate signature
x) state the name of the political party, movement, or coalition
xx) state the relevant facts in line with the Act on European Parliament Elections, Section 22, Paragraph 2.
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