SAMPLE APPLICATION FORM 
	
Secretariat of the Nomination Committee 
_____________________________________
_____________________________________
(Surname, name, patronymic of candidate, full and in genitive case, passport series and number, the issuing body and the date of issuance)
registered: ______________________
_____________________________________
residing at the address: ___________________
_____________________________________
tel. _________________________________
(home number, mobile number)
_____________________________________
(e-mail address)
_____________________________________
(Skype ID)	

APPLICATION
Please allow me to participate in the selection for the positions of independent members of the supervisory board of the Joint Stock Company “Khmelnytskoblenergo”.
I hereby ________________ to the disclosure of the content of my documents after the completion of the selection procedure.
(consent or do not consent)

I hereby ________________ to the presence of representatives of mass media, the public and representatives of International Finance Organisations and diplomatic institutions.
(consent or do not consent)
I attach the following documents to my Application:
- ___________________________________________________ ;
- ___________________________________________________ .
                 (full description of the list of attached documents)

I understand the terms for the participation and the selection procedure.

____ _____________ 20___	_____________
                                                      signature