Notification of Home Member State

Standard form for the notification of Home Member State

Date: 22 October 2015

ESMA/2015/1596

1.* Issuer Name:

1.bis. Formerly known as¹:

2.* Registered office:

3. LEI²:

3.bis National company register number³:

4.* Home Member State⁴:

5.* Triggering event⁵:

• Issuer of shares admitted to trading article 2(1)(i)(i)
• Issuer of debt securities denominated less than EUR 1,000 admitted to trading article 2(1)(i)(i)
• Issuer of other securities⁶ article 2(1)(i)(ii)
• Change of home Member State article 2(1)(i)(iii)

6.* Member State(s) where the issuer's securities are admitted to trading⁷:

6. bis. Former home Member State (if applicable)⁸:

7. NCAs the form is required to be filed with⁹:

8*. Date of notification:

9. Start date of 3 year period¹⁰:

10. Additional information¹¹:

11.* Contact details:

Issuer’s address:

Person responsible within the issuer for the present notification:

E-Mail address:

Telephone:

(* Mandatory information)

Information on filing procedures:

Notes

1. In case of a change of the company name compared to the previous disclosure, please provide the issuer’s former company name. In case of a first time disclosure, no information on an earlier name change is required.
2. Legal entity identifier.
3. In case the LEI is unavailable, please provide for identification purposes the number under which the issuer is registered with the business register of its country of incorporation.
4. The home Member State pursuant to article 2(1)(i) of Directive 2004/109/EC.
5. The criteria upon which the home Member State has been determined.
6. For example debt securities denominated at least EUR 1,000, units of collective investment undertaking of the closed end-type.
7. Only securities admitted to trading on regulated markets shall be taken into account.
8. Information required in case the issuer chooses a new home Member State pursuant to article 2(1)(i)(iii).
9. According to article 2(1)(i), second subparagraph of Directive 2004/109/EC.
10. In case of a choice of home Member State pursuant to article 2(1)(i)(ii) of Directive 2004/109/EC.
11. Please provide any relevant additional information.