FORM FOR THE SUBMISSION OF COMPLAINTS CONCERNING ALLEGED UNLAWFUL STATE AID OR MISUSE OF AID The mandatory fields are marked with a star (*). 1. Information regarding the complainant First Name:* Karolis Surname:* Kačerauskas Address line 1:* Law Firm “Ellex Valiunas” Address line 2: Jogailos str. 9/1 Town/City:* Vilnius County/State/Province: Postcode:* LT-01116 Country:* Lithuania Telephone: +370 5 2 681 888 Mobile Telephone: +370 640 41058 E-mail address:*
[email protected] Fax: 2. I am submitting the complaint on behalf of somebody (a person or a firm) Yes* No* If yes, please also provide the following information Complainant 1 Name of the person/firm you represent*: Interneto žiniasklaidos asociacija Registration nr. of the entity: 302334852 Address line 1:* Gynėjų str. 16 Address line 2: Town/City:* Vilnius County/State/Province: Postcode:* LT-01109 Country:* Lithuania Telephone 1: +370 659 13149 Telephone 2: E-mail address:*
[email protected] 1 Fax: Please attach proof that the representative is authorised to act on behalf of this person/firm.* Power of Attorney issued by Interneto žiniasklaidos asociacija to the law firm “Ellex Valiunas" is enclosed to this Complaint as . The representative authorised to sign the Power of Attorney is indicated in the extract of the register of legal entities enclosed to this Complaint as Annex No. 15. Yes* No* Complainant 2 Name of the person/firm you represent*: UAB All Media Lithuania Registration nr. of the entity: 121393020 Address line 1:* Kalvarijų str. 135 Address line 2: Town/City:* Vilnius County/State/Province: Postcode:* LT-08221 Country:* Lithuania Telephone 1: +370 5 203 0250 Telephone 2: E-mail address:*
[email protected] Fax: Please attach proof that the representative is authorised to act on behalf of this person/firm.* Power of Attorney issued by UAB All Media Lithuania to the law firm “Ellex Valiunas” is enclosed to this Complaint as Annex No.