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New Card Application

Guarantor: The Capital City of Prague, Marinsk nmst 2, 110 01, Reg. No.: 00064581
Administrator: Opertor ICT a.s., Jungmannova 36/31, 110 01 Prague 1, Reg. No.: 02795281
Please complete the form legibly with block letters and include Czech diacritic symbols. Space for the bar code
*) These details are mandatory. If they are not provided, the card application cannot be accepted.

REASON FOR NEW CARD

First card Replacement card Replacement due to end of validity


This is my first card. I have never had a Ltaka or Loss, damage, destruction, theft, change in details, at Validity may be verified at any validator.
an Opencard. own request

Card No. of card being replaced

APPLICANT DETAILS From the specified data the cardholders name, surname and photo will be printed on the card.

Name*

Surname*
Space for
photo*
Date of birth* Title before name Title after name
45 x 35 mm
Phone*
You will be informed by SMS when your Ltaka card will be ready for pick-
up at the specified contact point.

E-mail address

I do not agree to storage


of my photograph.
Correspondence address Orientation
The card will be sent to this address.
Street House number number

Municipality Postal code

CARDHOLDERS DECLARATION AND CONSENT


I hereby acknowledge that by submitting this application I am granting the Administrator permission to reserve data space in the cards memory chip and for the processors of these
applications to subsequently load the data for these card applications into the data space reserved for them on my card.

1) I hereby declare that all of the details that I have provided in this application are truthful and accurate.
2) The applicants rights and duties are set by the Terms and Conditions for Issuing and Using Chip Cards, which can be found at contact points and in electronic form on the website
www.litacka.cz. I hereby confirm by signing that I have become familiar with the current wording of the Terms and Conditions for Issuing and Using Chip Cards, that I understand
its content, that I agree with them and that I shall abide by them.
3) A fee is charged for submitting this application based on the valid price list applicable at the time. More information can be found on www.litacka.cz.
4) I hereby acknowledge that this application bearing my signature is an expression of consent to entering into an agreement with the Capital City of Prague, the subject of which is
issuing a card and administering its life cycle, including ensuring interaction with cardholders using available card applications. This agreement is entered into with
OpertorsICTsa.s. on behalf of and at the expense of the Capital City of Prague.
5) I hereby acknowledge that I am fully aware of and agree to the voluntarily-provided personal data specified herein being processed in connection with administering the card and Applicants signature*
during operation of card applications. The personal data made available by cardholders will be processed for the purpose of issuing the card via card applications, administering
the card's life cycle and using the card and the services.
6) Personal data consisting of the applicants name, surname and photograph will continue to be processed by the operators of the respective card applications. In such case,
thesadministrator, pursuant to Act No. 101/2000 Coll., on personal data protection, as amended, shall be the processor of the respective card application. Personal data processors
may also include parties with whom the respective personal data administrator has entered into a written agreement on processing personal data. Information about specific
administrators and processors of personal data can be found on www.litacka.cz.
7) I hereby agree to sending information and commercial disclosures related to the Ltaka system. YES NO

LEGAL GUARDIANS CONSENT TO THIS APPLICATION


I hereby honestly declare that I am the specified persons legal guardian.
Name

Surname Legal guardians signature

Date of birth Title before name Title after name

METHOD OFCOLLECTION AND PAYMENT - TO BE COMPLETED BY OFFICIAL


Total amount due Payment method
Card acceptance method First card, replacement Replacement due to end
for another reason of validity Cash upon submission Details verified
Branch code
In person at branch 100 CZK 50 CZK Credit/debit card online
upon submission Acceptance place and date
Correspondence by registered mail 150 CZK 100 CZK By bank transfer

If a fee is paid for issuing a chip card, please send the payment to the bank account specified at esk spoitelna a.s., account
number 300300312/0800, at the latest within three days of the submitting your application. As the variable symbol, please use
the application number (specified in the upper right-hand corner). In the message for the recipient, please write Ltaka.