Commission notice

Information on the identity of the requested person 

Name:
Forename(s):

Maiden name, where applicable:
Aliases, where applicable:
Sex:
Nationality:
Date of birth:
Place of birth:
Residence and/or known address:
Language(s) that the requested person understands (if known):
Distinctive marks/description of the requested person:
Information on the requesting third State authority and the extradition request 
 
1. Issuing third State: 
(Judicial) authority which issued the arrest warrant /extradition request: 
Name of its representative: 
Post held (title/grade):
File reference:
Address:
Contact details: 
2. Extradition request [tick box]: 
□ For the purpose of prosecution; 
□ For the purpose of executing a sentence or a detention order. 
Extradition request reference number: 
3. Information on the offences the person concerned is accused of: 

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The extradition request relates to, in total …… [number] offences. 
Description of the circumstances in which the offence(s) was (were) committed, including 
the time, place and degree of participation in the offence(s) by the requested person: 
 
 
Nature and legal classification of the offence(s), including the applicable statutory 
provision/code: 
Grounds for considering the extradition request as unfounded, abusive, in particular 
politically motivated and/or requests, which raise the Charter or the ECHR concerns: 
 (please specify): 
 
 
Contact details of the State transmitting information on the extradition request 
State: 
Competent authority: 
Contact person: 
Post held: 
File reference: 
Contact details (email/phone numbers): 
Date and signature

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