Karta Rejestrowa Firmy

COMPANY REGISTRATION FORM of a Member of the Polish Chamber of Commerce for Electronics and Telecommunications

1. Full company name1: 2. Abbreviation or acronym: 3. Company site address2: 4. Phone/fax number 5. General e-mail address: 6. Web site address: 7. Year of foundation: 8. Company registration3: 9. Initial capital (PLN): 10. Legal form4: 11. Organizational form5: 12. NIP: 13. REGON: 14. Ticker: 15. Employees6: 16. Company ownership7: 17. Company management8: 18. Branches and divisions9: 19. Business profile description10: 20. Activity description (briefly – company profile) in Polish: (max ½ A4 page; font 10 pts) 21. Activity description (briefly – company profile) in English: (max ½ A4 page; font 10 pts) 22. Company expectations from another entities or KIGEiT (business contacts, assets, know-how etc.): (max ½ A4 page; font 10 pts) 23. Total sales11 (million PLN) in year:

1 Fields marked in red are obligatory. 2 City, zip code, street, no, province. 3 Date, city, registration office, register number. 4 Use proper form in accordance with an art. 36 of the Act of 20th August 1997 on the National Court Register (a uniform text Dz. U. z 2001 Nr 17, poz. 209, with later modifications) i.e.. sp. z o.o., S.A., s.c., sp. jawna, osoba fizyczna, przedsiębiorstwo państwowe, przedsiębiorstwo zagraniczne, spółdzielnia, firma Skarbu Państwa, jednostka badawczo- rozwojowa. 5 Use a proper form: przedsiębiorstwo produkcyjne, hurtownia, sklep, przedsiębiorstwo usługowe. 6 Apply a full-time post conversion. 7 List all shareholders and their shares in per cents. 8 Name, title, telephone, fax, e-mail address. 9 Name, address, telephone, fax, e-mail address. 10 Put in an essential activity: manufacturing, trade, services, others (if so list them). 11 A code range form the list below may be used: Total sales (million PLN/year)Code range:No more then 1B1More then 1 but no more then 5B2More then 5 but no more then 10B3More then 10 but no more then 50B4More then 50 but no more then 100B5More then 100 but no more then 200B6More

- 1 - Krajowa Izba Gospodarcza Elektroniki i Telekomunikacji ul. Stępińska 22/30; 00-739 Warszawa, tel.: +48 22 840 6522, 851 0309; fax: +48 22 851 0300, e-mail: [email protected]; www.kigeit.org.pl COMPANY REGISTRATION FORM of a Member of the Polish Chamber of Commerce for Electronics and Telecommunications

 2016  2015  2014 24. Operating bank(s) (bank name, ac- count(s) number(s): 25. Received authorizations: 26. Received certifications: 27. Membership of another chambers of commerce: 28. Membership of another economic or- ganizations: 29. Company logo (a graphic file may be attached): 30. Name and title of person accepting the form, date:

then 200 but no more then 500B7More then 500B8

- 2 - Krajowa Izba Gospodarcza Elektroniki i Telekomunikacji ul. Stępińska 22/30; 00-739 Warszawa, tel.: +48 22 840 6522, 851 0309; fax: +48 22 851 0300, e-mail: [email protected]; www.kigeit.org.pl