/EIC-

EIC Code Request Company Full Name: * Company Display Name (max. 13 characters capitals only): * BE Address: *

Postal Code: * City: * Country: * Contact person: * E­mail address: * Telephone Fax: EAN: VAT: * Company Function: * Issuing Office Identification

Type

22

x

Identification ** (max. 12 characters)

Check digit (To be completed by Elia) *

Suggested EIC Code:

Request date: * Mandatory fields (**) The EIC­code can not be changed and must be a ‘non­significant’ code, therefore Elia will assign one.