Information element Description Type of information element

Name of authorised representative: Official name of the authorised representative linked to the national tax number or to the identification code/number provided when registering in the business register in the Member State.

— If the authorised representative is a legal person (company), provide the name of the company F

— If the authorised representative is a natural person, provide: — First name — Last name F

Legal address of authorised representative: Official address of the authorised representative. The authorised representative shall be established on the territory of the Member State.

— Street name M

— Street number M

— Postal code M

— Location M

— Province M*

— Municipality M*

— Website address (if a website address exists) M

Contact person of authorised representative: Person associated with the authorised representative as point of contact. It is an individual who is selected as the initial or regular contact point for that authorised representative. The contact person shall be established on the territory of the Member State.

— First name M

— Last name M

— Phone number Business phone. M

— Email address Business email address. M

— Address Business address of the contact person.

— Street name M

— Street number M

— Postal code M

— Location M

— Province M*

— Municipality M*

National identification code/business registration code For authorised representatives that are legal persons, the identification code/number provided when registering in the business register in the Member State. F

National tax number Tax number of the authorised representative in the Member State. M*

Name of the represented producer(s): — If the producer is a legal person (company), provide the name of the company — If the producer is a natural person, provide: — First name — Last name Official name of the producer(s) represented by the authorised representative as linked to the national/European tax number of the producer or to the identification code/number provided when registering in the business register in the country where the producer is established. If the authorised representative represents more than one producer and the Member State provides for the authorised representative to be registered once, the authorised representative shall indicate separately the name and the contact details of each one of the represented producers. M

Contact details of the represented producer(s): Official contact details of the producer(s) represented by the authorised representative.

— Phone number M

— Email address M

— Address M

— Street name M

— Street number M

— Postal code M

— Location M

— Country M

— Website address (if a website address exists) F

Categories of the represented producer's annual turnover of EEE Indication of the represented producer's annual turnover. Member States requesting this information element must provide different ‘categories of annual turnover of EEE’ so that the represented producer can choose the relevant category. If the authorised representative represents more than one producer and the Member State provides for the authorised representative to be registered once, the authorised representative shall indicate separately, for each one of the represented producers, the category of annual turnover of EEE. M*

Category/categories of EEE Description of the category or categories of EEE that the represented producer places on the market of the Member State by number pursuant to Annex III to Directive 2012/19/EU. If the authorised representative represents more than one producer and the Member State provides for the authorised representative to be registered once, the authorised representative shall describe separately the categories of EEE that each one of the represented producers places on the market of the Member State. M

Sub-category/sub-categories of EEE Description of the sub-category or sub-categories of EEE that the producer places on the market of the Member State as applied in the Member State. If the authorised representative represents more than one producer and the Member State provides for the authorised representative to be registered once, the authorised representative shall describe separately the sub-categories of EEE that each one of the represented producers places on the market of the Member State. M*

Type of EEE (household or other than household equipment) For each one of the categories or, if applicable, the sub-categories of EEE that the represented producer places on the market of the Member State, indication of ‘household’ or ‘other than household’ equipment. M*

Brand name of EEE For each one of the categories or, if applicable, the subcategories of EEE that the represented producer places on the market of the Member State, the arbitrarily adopted name that is given by a producer to the EEE to distinguish it as produced or sold by that producer and that may be used and protected as a trademark. M*

Producer responsibility: Information on how the represented producer meets the responsibilities set out in Directive 2012/19/EU in the Member State. If the same producer or the authorised representative on behalf of the producer has set up an individual compliance scheme for certain categories of EEE and has joined a collective compliance scheme for others, both should be indicated. If the authorised representative represents more than one producer and the Member State provides for the authorised representative to be registered once, the authorised representative shall indicate separately how each one of the represented producers meets the responsibilities set out in Directive 2012/19/EU in the Member State.

The producer or the authorised representative on behalf of the producer has set up an individual compliance scheme in the Member State. Yes/No M

If the answer is ‘Yes’, provide additional information about the individual compliance scheme. Description of additional information that the producer or the authorised representative on behalf of the producer shall submit in relation to the individual compliance scheme. M*

The producer or the authorised representative on behalf of the producer has joined collective compliance scheme(s) in the Member State Yes/No M

Financing responsibility: Information on the form of the guarantee that each represented producer provides when placing a product on the market of the Member State pursuant to Article 12 of Directive 2012/19/EU.

The producer or the authorised representative on behalf of the producer participates in one or more collective compliance schemes. Yes/No M

The producer or the authorised representative on behalf of the producer provides a recycling insurance. Yes/No M

The producer or the authorised representative on behalf of the producer provides a blocked bank account. Yes/No M

Other (please specify) If the financial guarantee in a Member State does not have any of the forms mentioned above, the authorised representative shall describe the form of the guarantee. M

Declaration ‘I/We declare that the above-named authorised representative has been appointed with a written mandate by the represented producer(s) pursuant to Article 17(3) of Directive 2012/19/EU on waste electrical and electronic equipment.’ Declaration of the authorised representative or, where applicable, of the third party acting on behalf of the authorised representative that the authorised representative has been appointed by written mandate according to Article 17(3) of Directive 2012/19/EU on waste electrical and electronic equipment. In case of electronic forms, this declaration shall be marked (check box). M