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

APPLICATION
Please allow me to participate in the selection for the position of an independent member of the supervisory board of the Private Joint Stock Company “National Power Company “Ukrenergo”.
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.

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                                                      signature