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Application FormCHAIRPERSON OF A BOARD OF APPEALVEXT/19/17/AD13/BOA_ChairpersonCandidates should note that the information provided in this form constitutes a basis for appreciation of the eligibility and selection criteria expressed in the vacancy notice. It is therefore required that all sections of this form are duly completed. Relevant information should be provided in such detail that it allows accurate appreciation. Particular attention should be paid to the section on Professional experience and related fields.The information provided in this application form is subject to EU legislation on protection of personal data and confidentiality of information.1.Surname(s)Forename(s)Maiden name (if applicable) FORMTEXT ???? FORMTEXT ????? FORMTEXT ?????2.GenderF FORMCHECKBOX FORMCHECKBOX M FORMCHECKBOX FORMCHECKBOX 3.Place of birthDate of birth (dd/mm/yy)Present nationality (if several, indicate all) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4.Address for correspondenceEmail address FORMTEXT ????? FORMTEXT ?????Tel. Work FORMTEXT ????? FORMTEXT ?????Tel. Home FORMTEXT ????? FORMTEXT ?????Mobile Tel. FORMTEXT ?????5.Contact person? (if different from 4.)Email address FORMTEXT ????? FORMTEXT ?????Tel. Work FORMTEXT ????? FORMTEXT ?????Tel. Home FORMTEXT ????? FORMTEXT ?????Mobile Tel. FORMTEXT ?????6.Higher Education(Continue on additional sheets if necessary)6.1.Degree/Diploma obtained? FORMTEXT ?????field of study FORMTEXT ?????Date of obtention of the Degree/Diploma?2 FORMTEXT ?????Period of StudyFrom (dd/mm/yyyy)To (dd/mm/yyyy) FORMTEXT ????? FORMTEXT ?????University/establishmentName FORMTEXT ?????Address FORMTEXT ?????Standard duration of Studies to obtain this degree/diploma1 yr FORMCHECKBOX 2 yrs FORMCHECKBOX 3 yrs FORMCHECKBOX 4 yrs or more FORMCHECKBOX 6.2.Degree/Diploma obtained?2 FORMTEXT ?????field of study3 FORMTEXT ?????Date of obtention of the Degree/Diploma?2 FORMTEXT ?????Period of StudyFrom (dd/mm/yyyy)To (dd/mm/yyyy) FORMTEXT ????? FORMTEXT ?????University/EstablishmentName FORMTEXT ?????Address FORMTEXT ?????Standard duration of studies to obtain this degree/diploma1 yr FORMCHECKBOX 2 yrs FORMCHECKBOX 3 yrs FORMCHECKBOX 4 yrs or more FORMCHECKBOX 6.3.Degree/Diploma obtained?2 FORMTEXT ?????field of study3 FORMTEXT ?????Date of obtention of the Degree/Diploma?2 FORMTEXT ?????Period of StudyFrom (dd/mm/yyyy)To (dd/mm/yyyy) FORMTEXT ????? FORMTEXT ?????University/EstablishmentName FORMTEXT ?????Address FORMTEXT ?????Standard duration of studies to obtain this degree/diploma1 yr FORMCHECKBOX 2 yrs FORMCHECKBOX 3 yrs FORMCHECKBOX 4 yrs or more FORMCHECKBOX 7.General, Specialist and further training or other courses(Continue on additional sheets if necessary)7.1.Training/Course attended FORMTEXT ?????Date of obtention of the Diploma/Certificate FORMTEXT ?????Period of StudyFrom (dd/mm/yyyy)To (dd/mm/yyyy) FORMTEXT ????? FORMTEXT ?????University/EstablishmentName FORMTEXT ?????Address FORMTEXT ?????7.2.Training/Course attended FORMTEXT ?????Date of the obtention of the Diploma/Certificate FORMTEXT ?????Period of StudyFrom (dd/mm/yyyy)To (dd/mm/yyyy) FORMTEXT ????? FORMTEXT ?????University/establishmentName FORMTEXT ?????Address FORMTEXT ?????7.3.Training/Course attended FORMTEXT ?????Date of Obtention of the Diploma/Certificate FORMTEXT ?????Period of StudyFrom (dd/mm/yyyy)To (dd/mm/yyyy) FORMTEXT ????? FORMTEXT ?????University/EstablishmentName FORMTEXT ?????Address FORMTEXT ?????8. Professional ExperienceIn this section, please list all the positions you have occupied in your Professional career. For each professional experience inserted, please specify the exact dates and percentage of working time dedicated to this position, and fill out all the required fields indicating how the experience is/was relevant for the profile sought. Please indicate also its relation to the area of intellectual property and, in particular, to the area of trade marks and/or designs. ! copy and paste this section as many times as necessary, Continue on additional sheets if necessary 8.1.Present or most recent post (gained after the relevant degree)From (dd/mm/yyyy)To (dd/mm/yyyy)Full timePart time (indicate %) FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????%EmployerName FORMTEXT ?????Address FORMTEXT ?????Job Title FORMTEXT ?????Description of Duties and Responsibilities FORMTEXT ?????Was this position in the field of Intellectual property (ip) FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please specify the tasks performed PLEASE INDICATE the exact dates spent in the field of ip when they do not cover the whole period indicated aboveFROM (dd/mm/yyyy)TO (dd/mm/yyyy)Was this position in the area of Trade marks and/or Designs? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please specify the tasks performedPLEASE INDICATE the exact dates spent in the area of trade marks and/or designs when they do not cover the whole period indicated aboveFROM (dd/mm/yyyy)TO (dd/mm/yyyy)Did this position involve managerial duties? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please specify and indicate, in particular, whether the position involved leading a team of collaboratorsPLEASE INDICATE the exact dates spent in managerial duties when they do not cover the whole period indicated aboveFROM (dd/mm/yyyy)TO (dd/mm/yyyy)Technical knowledge and experiencePlease indicate your technical knowledge and/or experience related to the specifications of the vacancy, in particular any professional experience/knowledge in relation with point 4b), such as: experience in legal case handling or equivalent activities, litigation, preparation and/or follow up of court cases, mediation and/or arbitration, technical external communication, in particular within the field of IP (conferences, trainings, seminars); any knowledge acquired in the area of IP legislation and case law (in particular eu tm and designs legislation) and European IP environment, including counterfeiting and infringement matters. 8.2.Previous Post (gained after the relevant degree)(copy and paste this section as many times as necessary, Continue on additional sheets if necessary)From (dd/mm/yyyy)To (dd/mm/yyyy)Full timePart time (indicate %) FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????%EmployerName FORMTEXT ?????Address FORMTEXT ?????Job Title FORMTEXT ?????Description of Duties and Responsibilities FORMTEXT ?????Was this position in the field of Intellectual property (ip)? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please specify the task performed PLEASE INDICATE the exact dates spent in the field of ip when they do not cover the whole period indicated aboveFROM (dd/mm/yyyy)TO (dd/mm/yyyy)Was this position in the area of Trade marks and/or Designs? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please specify the tasks performedPLEASE INDICATE the exact dates spent in the area of trade marks and/or designs when they do not cover the whole period indicated aboveFROM (dd/mm/yyyy)TO (dd/mm/yyyy)Did this position involve managerial duties? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please specify and indicate, in particular, whether the position involved leading a team of collaborators PLEASE INDICATE the exact dates spent in managerial duties when they do not cover the whole period indicated aboveFROM (dd/mm/yyyy)TO (dd/mm/yyyy)Technical knowledge and ExperiencePlease indicate your technical knowledge and/or experience related to the specifications of the vacancy, in particular any professional experience/knowledge in relation with point 4b), such as: experience in legal case handling or equivalent activities, litigation, preparation and/or follow up of court cases, mediation and/or arbitration, technical external communication, in particular within the field of IP (conferences, trainings, seminars); any knowledge acquired in the area of IP legislation and case law (in particular eu tm and designs legislation) and European IP environment, including counterfeiting and infringement matters. 9.Knowledge of languagesPlease indicate all your language skills and indicate your levels where appropriateMother tongue(s)Replace with mother tongue(s)Other language(s)comprehensionoral expressionwritten expression Replace with languageSELECT LEVELSELECT LEVELSELECT LEVELReplace with name of language certificateReplace with languageSELECT LEVELSELECT LEVEL SELECT LEVELReplace with name of language certificateReplace with language SELECT LEVELSELECT LEVEL SELECT LEVELReplace with name of language certificateReplace with languageSELECT LEVELSELECT LEVELSELECT LEVELReplace with name of language certificateReplace with languageSELECT LEVELSELECT LEVELSELECT LEVELReplace with name of language certificatedo you have professional experience of working in a language other than your mother tongue? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please indicate the language(s) and the type of tasks performedplease indicate your language of interview in case you are invitedThis language needs to be one of the languages of the EUIPO and different from your mother tongue SELECT LANGUAGE10.other experience and knowledgePlease indicate any other experience and knowledge relevant for the profile sought FORMTEXT ?????Do you have experience of working in a multicultural and/or international environment? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please specify where this experience was acquired.11.PublicationsContinue on additional sheets if necessaryType of publication(books, articles, lectures, etc.)YearTitleContent FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????12.relevant memberships of professional associations or similarPlease indicate any relevant memberships of professional associations or similar FORMTEXT ?????13.Other relevant information that the Selection Committee should know FORMTEXT ?????14.Period of notice required to leave your present post FORMTEXT ?????Final Declaration:I declare on my honour that the information provided in this form is true and complete FORMCHECKBOX yes FORMCHECKBOX noi declare on my honour that i am a national of one of the member states of the eu FORMCHECKBOX yes FORMCHECKBOX noi declare on my honour that i have not been convicted or found guilty of any criminal offence by any court FORMCHECKBOX yes FORMCHECKBOX noif appointed, I confirm my willingness to make a declaration of commitment to act independently in the public interest and in relation to interests which might be considered prejudicial to My independence FORMCHECKBOX yes FORMCHECKBOX noDate (dd/mm/yyyy) FORMTEXT ?????...................................................................................Name/Signature FORMTEXT ?????...................................................................................Please note that CVs will not be taken into considerationThe completed form should either:BE SENT BY EMAIL TO MBBCSecretariat@euipo.europa.eu BE SENT BY MESSENGER SERVICE TO:Chairperson of the Management Board European Union Intellectual Property Office Avenida de Europa, 4 E-03008 ALICANTE SPAINIf sent by messenger service, please mark the envelope as follows:CONFIDENTIALNOT TO BE OPENED BY THE MAIL SERVICE ................
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