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:
47
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
