Please provide the information requested and attach all relevant documents to this Form. The information provided in this Form is confidential to the extent possible to enable ERCA conduct its investigation. However, ERCA may disclose this information where necessary to assist its investigation. For the avoidance of doubt, you have the right to identify which information you consider confidential by submitting a request for confidentiality together with this Form.

I declare that the information in this Form and all supporting documents I have attached are accurate and provided to ERCA in good faith.