A P P L I C A T I O N F O R M f o r r e c o g n i t i o n

of professional qualification
1)
- professional qualification and oter co!petence
1)
Name of an activity: ......................................

I intend to practise the regulated activity in this form:

2)
as an employee or in the analogical relation
as an agent in trade acting under supervision of a trade holder
as an entrepreneur in the form of trade
in self-employment
Is the activity regulated in your Member State of originin the Member State
!here you come from:
yes
no
"ata about an applicant:
#irst name: ......
Surname: .....
Se$:
%)
male - female
"ate of birth: ...
&lace of birth 'country and city): ...
Nationality'ies): ......
&ermanent address: ..

(ddress for receiving correspondence:

))
..............

1
) "elete as appropriate.
2
) *ross the correct information in the frame.
3
) #ill in only if it is not identical !ith permanent address .
1
+ome phone: ..
Mobile phone: .
#a$: ...
,mail:
&ersonal data about a family member of an applicant:
-)
#amily relationship to!ards applicant: ..
#irst name: ..
Surname: .....
Se$:
%)
male - female
"ate of birth: ...
&lace of birth 'country and city):
Nationality'ies): ......
"ata about an authori.ed representative of an applicant:
/)
#irst name: ......
Surname: .....
(ddress: ...
&hone: ......
Mobile phone: .
#a$: ...
,mail:
Information on professional 0ualification 'diploma1 certificate or other
document):
2ype of diploma1 certificate or other document:
3)
.....

Number of diploma1 certificate or other document: ......

Issuance date of diploma1 certificate or other document: ...
Name1 address and country of educational establishment:

4
) #ill in only if an applicant is not a national of an ,4 Member State or ,uropean ,conomic (rea *ountry or
S!it.erland1 but is a family member of an ,4 Member State national or ,,( country national or S!it.erland
national.
5
) #ill in only if an applicant is represented by another person under the po!er of attorney.
6
) "iploma1 certificate or other document received upon completion of education 'university education1 post-
secondary education1 secondary education1 ) and training.
2
"uration of studies: .months
%)
5 years
%)

Information on professional e$perience 5 previous pursuit of the profession or
activity in 0uestion by an applicant:
2)
no
yes
in a dependant position:
full-time: from..to...6 in total......months
%)
5 years
%)
part-time: from....to..6 in total..............months
%)
5 years
%)
in an independent or leader position: from..to...6
in total..... months
%)
5 years
%)
Name1 address and country of an employer's):

........

,vidence attached by an applicant to an application:

2)
(. "ocuments proving identity of an applicant:
identity card
document that proves nationality
po!er of attorney
/)
7. "ocuments proving professional 0ualification:
diploma1 certificate or other document
description of the content and the scope of studies
evidence of professional e$perience
3
certificate of professional 0ualification issued by the competent authority in the Member
State of origin in the Member State !here the applicant comes from
8)
*. "ocuments proving other competence:
e$tract from the criminal record1 or
document that proves that an applicant has not been declared ban9rupt1 or
document that proves that an applicant practised the activity !ith the care of an upright
manager as an authori.ed agent or as statutory body or as a member of a statutory body
or as other body of legal entity upon its property the petition in ban9ruptcy has been
filled1 or
document that proves that the applicant has not been sub:ect to administrative or
disciplinary sanctions1 or
document that proves the applicant;s good physical or mental health1 or
document that proves the applicant;s sound financial management1 or
document that proves applicant;s insurance against the financial conse0uences of their
professional liability
In . day

(pplicant<s signature
Information for applicants:
An identity card, proof of nationality, evidence of professional qualification and evidence of other
competence are submitted authentic or as a copy.
Evidence of professional qualification and evidence of other competence must be translated into Czech
if they are not issued in Czech or if the international treaty, by which the Czech Republic is bound, does not
say differently.

7
) &rove only if the activity is regulated in the Member State of origin in the Member State !here the
applicant comes from
4
Attached evidence of other competence, with the eception of evidence of sound financial mana!ement,
may not be older than " months.
#nder current le!islation, namely Act $o. %"&'())& Coll. on Administrative *ees, an administrative fee
of C+, ())) is collected for reco!nition of a professional qualification. If the reco!nition authority is
a professional chamber, an internal rule of this chamber re!ulates the amount of the fee.
5