APPLICATION FOR OUT-OF-COURT PASSENGER DISPUTE RESOLUTION PROCEEDINGS
1.
Contact data of the entity settling the dispute
IMPORTANT: after completing the form, at the end of the application process, the form will have to be printed, signed, scanned and a scan attached as a necessary stage of completing the application process. When one year has passed since the date on which the flight subject to the application was operated or was to be operated, the application is not considered
1.1.
The entity to which the application is addressed:
Passengers’ Rights Ombudsman
The Passengers’ Rights Ombudsman deals with resolving civil law disputes concerning pecuniary claims arising from the provisions of the Regulation No 261/2004/EC or the Regulation No 2111/2005/EC.
Proceedings at the Passengers’ Rights Ombudsman, concerning disputes arising from the Regulation No 261/2004/EC are related to flights from airports located on the territory of the Republic of Poland serviced by the EU air carriers as well as flights from third countries to these airports serviced by the EU air carriers.
1.2.
Full postal address: ul. Marcina Flisa 2, 02-247 Warsaw, Poland
2.
Designation of the parties
2.1.
Name and surname of the applicant:
Male
Female
Company
2.2.
Applicant’s address of residence:
Street
House number
Apartment number
post code
town/city
2.3.
Correspondence address (if different than the one given above):
The same as indicated above
Street
House number
Apartment number
post code
town/city
2.4.
E-mail address (remember to agree to the consent to the delivery of letters and exchange information with the use of electronic means of communication)
I consent to the delivery of letters to parties to the proceedings and exchange information between parties to the proceedings with the use of electronic means of communication (in point 2.4 indicate your e-mail address). If you file such a declaration the exchange of information between you and the entrepreneur as well as the delivery of the Ombudsman’s letters will be via electronic mail. If you do not consent, the correspondence will be sent in the paper form by registered mail.
2.5.
Pnone (optional)
2.6.
How many passengers does the application concern: (The application may concern several passengers if they jointly submit the application, the complaint concerns the same flight and they have a common interest in the dispute resolution)
APPLICATION SHOULD BE SUBMITTED FOR EACH FLIGHT SEPARATELY, IF APPLICABLE TO THE OUT AND BACK FLIGHT, 2 APPLICATIONS SHOULD BE SUBMITTED
2.7.
Entrepreneur’s name (e.g. an air carrier) with which passengers are in a dispute:
AEGEAN Airlines Headquarters (A3 / AEE) - 31, Viltanioti Str. 145 64, Kifisia, Athens, Greece GRECJA
AER LINGUS (EI / EIN) - Head Office Dublin Airport Ireland Oddział w Polsce Sielecka 22 00-738 Warszawa
AEROITALIA (XZ/AEZ) - Linee Aeree Regionali Europee Via Paolo Bembo, 70 - 37062 Dossobuono di Villafranca (VR) Italy
AIR ARABIA PJSC (3L/ADY) - PUBLICZNA SPÓŁKA AKCYJNA ODDZIAŁ W POLSCE ul. NOWOLIPKI nr 4 lok. 21 00-153 WARSZAWA
AIR BALTIC (BT / BTI) - Tehnikas iela 3, Starptautiskā lidosta "Rīga", Mārupes novads, Rīga, Latvija LV-1053 Air Baltic Corporation S.A. działający w Polsce przez: Air Baltic Corporation S.A. Oddział Zagranicznego Przedsiębiorcy ul. Zachodnia 3 Opacz Kolonia 05-816
AIR CAIRO (SM / MSC) - 6 El-Safa street, Sheraton Heliopolis, Cairo - Egypt
AIR CANADA (AC / ACA) - Oddział w Polsce ul. Nowolipki 4/21 00-153 Warszawa
AIR CHINA LIMITED S A - Oddział w Polsce ul. Tytusa Chałubińskiego 8, 00-613 Warszawa
AIR DOLOMITI (EN/DLA) - Via Paolo Bembo, 70 37062 Dossobuono di Villafranca di Verona (VR) Italy
AIR EUROPA LINEAS AEREAS, SAU (UX) - CIF A-07129430 Ctra. Arenal - Llucmajor Km, 21.5 - 07620 Llucmajor Baleares
AIR FRANCE (AF / AFR) - Oddział w Polsce Spektrum Tower ul. Twarda 18 00-105 Warszawa
AIR MALTA (KM/AMC) - Air Malta plc. Level 2, Skyparks Business Centre Malta International Airport Luqa, Malta. LQA 4000
AIR MONTENEGRO - Beogradska 10, 81000 Podgorica, Czarna Góra, PIB: 03344312
AIR SERBIA (JU) - Jurija Gagarina 12, 11000 Novi Beograd, Serbia Oddział w Polsce ul. Pańska 96, lok. 61 00-837 Warszawa
ALITALIA (AZ / AZA) - ul. Viale Marchetti Alessandoro Nr 111 Cap 00148 Rzym
ALMASRIA (UJ) - Universal Airlines Building Cairo International Airport (Terminal 1) ALMAZA, Cairo, Egypt 11776 Cairo, EGYPT
AMC AVIATION SP. Z O.O. (AMQ) - AMC Aviation Sp. z o.o. Biuro Zarządu (siedziba główna) ul. Ruchliwa 15 02-182 Warszawa, Poland Oddział Lotnisko Modlin (baza) Generała Thommee 1a, Hangar nr 13 05-102 Nowy Dwór Mazowiecki, Poland
AUSTRIAN AIRLINES (OS / AUA) - Oddział w Polsce ul. Tadeusza Czackiego 15/17 00-043 Warszawa
BRAVO AIRWAYS (BAY) - 7 Shulyavska St., Kyiv 04116 Ukraina
BRITISH AIRWAYS (BA / BAW) - British Airways PLC działający w Polsce przez: British Airways Oddział w Polsce ul. Nowolipki 4/21 00-153 Warszawa
BRUSSELS AIRLINES (SN / BEL) - Oddział w Polsce ul. Bielska 28 02-394 Warszawa
BULGARIA AIR (FB / LZB) - 1 Brussels Blvd Sofia Airport 1440 Sofia Bulgaria Oddział w Polsce Solec 81B /P-7 00-382 Warszawa
CHINA AIRLINES LTD (CI/CAL) - Tajwan (Republika Chińska) Dystrykt Zhongshan Tajpej ul. Nanjing, Nr 131,Sec.3, Lok. 2f. 10410, Tajpej Oddział W Polsce ul. FLORY 9, lok. 5 00-586 Warszawa
CHINA SOUTHERN AIRLINES (CZ) - Head Office China Southern Airlines Company Ltd, 278 Ji Chang Rd. Guangzhou 510405 China
CONDOR Flugdienst GmbH (DE/CFG) - Kelsterbach An der Gehespitz 50, 63263 Neu-Isenburg
CORENDON AIRLINES TURISTIK HAVA Tașimacilik A.Ş. - (XC / CA) - Oddział W Polsce ul. Lekarska, Nr 2, Lok. 1 00-610 Warszawa
CZECH AIRLINES A.S. (OK / CSA) - Evropska 846/176a 160 00 Praha 6-Vokovice Czech Republic
DELTA AIR LINES (DL) - Dział obsługi klienta PO Box 20980 Departament 980 Atlanta, GA 30320-2980
DEUTSCHE LUFTHANSA S.A. (LH / DLH) - Oddział w Polsce ul. Tadeusza Czackiego nr 15/17, 00-043 Warszawa
EASY JET Airline Company Limited (U2 / EZY) - Hangar 89 London Luton Airport Bedfordshire LU2 9PF United Kingdom
EDELWEISS AIR AG (WK/EDW) - Airport Kloten 8058 Zurich
EGYPTAIR (MS) - Admin. Complex middle Bldg. 4th Floor Finger 8 room 12 Airport Road,PO Box 11776, Kair, Egipt
EL-Al ISRAEL AIRLINES (LY / ELY) - P.O.Box 41 Lotnisko Ben Guriona 7015001 Izrael
ELECTRA AIRWAYS (EAF) - 51, Aleksander Malinov Blvd. Metrocity Office Building 5th floor, Office A7 1712 Sofia, Bulgaria tel.: +359 2 9533331 fax: +359 2 9533336 email : office@electra-airways.com
EMIRATES (Rządowa Spółka Handlowa) (EK / UAE) - Oddział w Polsce ul. Złota 59 00-120 Warszawa
ENTER AIR sp. z o.o. (E4 / ENT) - ul. KOR 74 02-146 Warszawa
EUROWINGS GmbH (EW / EWG) - Waldstraße 249, 51147, Cologne Germany
FINNAIR (AY / FIN) - Oddział w Polsce ul. Piękna 68 00-672 Warszawa
FLY DUBAI (FZ/FDB) - Oddział W Polsce ul. Nowolipki 4 lok. 21 00-153 Warszawa
FLY EGYPT (FT/FEG) - 1 Gad El Haq, Sheraton Heliopolis, Cairo, Egypt, 11799
FLY PLAY PLAY AIRLINES (OG) - Suðurlandsbraut 14 108 Reykjavik, Iceland
FLYLILI (FL/LIL) - 67-77 Biharia Street, E Building, Entrance 2, District 1, Zip Code 013981, Bucharest
FREEBIRD AIRLINES - Çobançeşme Mah. Sanayi Cad. Simetri Ofis No:60 Kat:4-5 34197 Bahçelievler – İstanbul / Türkiye, Turcja
GETJET AIRLINES (GW/GJT) - Laisvės Ave. 10, Business Garden, A corpus, 04215 Vilnius, Lithuania
HAINAN AIRLINES LTD. (HU) - Comprehensive Office Building No.21,Hainan Airlines Haikou Meilan Base, No.9, Meilan Airport Road, Meilan District, Haikou City, Hainan Province; Postcode:570203 Oddział w Polsce Ul. Sienna 72 lok.3 00-833 Warszawa
HELVETIC AIRWAYS (2L/OAW) - Egglirain 24 8832 Wilen Schweiz
IBERIA AIRLINES (IB) - z siedzibą w Martinez Villergas 49 28027 Madryt, Hiszpania
ITA AIRWAYS (AZ) - Italia Trasporto Aereo SpA Via Venti Settembre 97 00187 Roma RM, Italy
JETSTAR AIRWAYS (JQ / JST) - PO Box 4713, Melbourne, VIC 3001, Australia
KLM S.A. (KL / KLM) - Oddział w Polsce Spektrum Tower ul. Twarda 18 00-105 Warszawa
KM MALTA AIRLINES LTD (KM) - Level 3, Valletta Buildings, South Street, Valletta VLT 1103, Malta
MAVI GÖK HAVACILIK A.Ş. (MGA) (4M/MGH) - Barbaros Mh. Serik E CD. E Blok nr: 419E/2 Aksu, Antalya/Türkiye, Turcja
NESMA AIRLINES (NE/NMA) - 5 El Madina St., El Nozha El Gedida, Heliopolis, Cairo – Egypt.
NORDIC REGIONAL AIRLINES OY NORRA (N7) - Address Tietotie 9 01530 Vantaa, Finland, Finlandia
NORSE ATLANTIC AIRWAYS AS (N0/NBT) - Floyveien 14, 4838 Arendal, Norway
NORWEGIAN AIR INTERNATIONAL LIMITED (D8) - Imbus House, Dublin Airport Co. Dublin, IRLANDIA
NORWEGIAN AIR NORWAY AS (DH) - Oksenøyveien 3, 1366 Lysaker, NORWEGIA
NORWEGIAN AIR SHUTTLE ASA (DY) - Oksenøyveien 3, 1366 Lysaker, NORWEGIA
NORWEGIAN AIR SWEDEN AB (LE) - Box 242 19047 Stockholm – Arlanda, SZWECJA
NORWEGIAN AIR UK LIMITED (DI) - First Point, Buckingham Gate, Gatwick Airport, RH6 0NT, ANGLIA
NOUVELAIR (BJ / LBT) - الطيران الجديد تونس 14, Boulevard Habib CHRITA, Cite Jardins, 1002 Tunis
PEGASUS AIRLINES (PC / PGT) - Aeropark Yenişehir Mah. Osmanlı Bulvarı No:11 34912 - Kurtköy Istanbul, Turkey Oddział w Polsce ul. Lekarska 2 lok. 1, 00-610 Warszawa
PLL LOT (LO / LOT) - ul. KOR 43 02-146 Warszawa
PLUS ULTRA LÍNEAS AÉREAS, SA - Avenida de Europa 22, 28108 Alcobendas, Madryt
QATAR AIRWAYS q.c.s.c. (spółka akcyjna) (QR / QTR) - Oddział w Polsce ul. Chłodna 51 00-867 Warszawa
RED SEA AIRLINES (RSX) - 8 Mokhtar Saeid - Pole golfowe Misr El Gedida, Kair, Egipt
RYANAIR DAC (FR / RYR) - Corporate Head Office Dublin Airport Ireland Oddział w Polsce ul. Cybernetyki 21 02-677 Warszawa
RYANAIR SUN S.A. (BUZZ) - (RR / RYS) - ul. Cybernetyki 21 02-677 Warszawa
RYANAIR UK (RK) - Enterprise House, 2nd Floor Bassingbourn Road, CM24
SATA AZORES AIRLINES (S4) - Rua Dr. José Bruno Tavares Carreiro, n 6 |7º Piso 9500-119 Ponta Delgada Azores – Portugal
SCANDINAVIAN AIRLINES SYSTEM - SAS (SK / SAS) - Oddział w Polsce Al. Jana Pawła II 29 00-867 Warszawa
SKY VISION AIRLINES (SE) - Building No. 4, Ebad Al-Rahman Street off Mostafa Refaat, Block 1172 – Sheraton Heliopolis - El Nozha – Cairo
SKYEXPRESS (Cretan Aeronautical Operations) - Heracleiou Airport Stan N K 0, Neas Alikarnasso / Heracleiou, 71601, Grecja
SKYLINE EXPRESS AIRLINES (QU / UTN) - Limited Liability Company 6, Volodymyra Sosyury St., Kyiv, 02090, Ukraine Oddział w Polsce LINIA LOTNICZA "SKYLINE EXPRESS" SPÓŁKA Z OGRANICZONĄ ODPOWIEDZIALNOŚCIĄ Aleje Jerozolimskie 96 00-807 Warszawa
SKYUP AIRLINES LTD. (PQ/SQP) - Kharkivske shose, 201/203-2a, 02121 Kyiv ODDZIAŁ W POLSCE „AWIAKOMPANIJA SKAJAP" sp. z o.o. ul. W.Rzymowskiego nr 53 02-697 Warszawa
SKYUP MT LTD (U5/SEU) - SKYUP MT LTD Europa Business Centre, Level 3 - 701, Dun Karm Street, Birkirkara BKR 9034, Malta
SMARTWINGS A.S. (QS / TVS) - K letisti 1068/30 160 08 Praga 6
SMARTWINGS POLAND sp. z o.o. (3Z / TVP) - ul. Gordona Bennetta 2B 02-159 Warszawa
SUN EXPRESS (XQ / SXS) - Güneş Ekspres Havacilik A.S. z siedzibą w Antalyi, Turcja Yenigὅl Mahalesi Nergiz Sokak No:84, PK:07230, Muratpaşa- Antalya, Turcja
SWISS INTERNATIONAL AIRLINES S.A (LX / SWR) - Oddział w Polsce ul. Tadeusza Czackiego 15/17 00-043 Warszawa
TAILWIND HAVAYOLLARI A.Ş. (TWI) - Yesilköy Mah. Ataturk Cad. Dtm Site A2 Blok Apt. Nr: 10/395 34149 Bakirköy / Stambuł / Türkiye
TAP PORTUGAL (TP / TAP) - Edifício 25 do Aeroporto de Lisboa, parish of Olivais, municipality of Lisbon, 1700-008 Lisbon, Portugalia
TRANSAVIA - Piet Guilonardweg 15 1117EE Schiphol
TUI AIRLINES NEDERLAND B.V. (OR / TFL) - Volmerlaan 3, 2288GC Rijswijk Holandia
TURKISH AIRLINES (TK / THY) - TURK HAVA YOLLARI S A Oddział w Polsce Al. Jerozolimskie 123A 02-017 Warszawa
UKRAINE INTERNATIONAL AIRLINES (PS / AUI) - ul. BUKOWIŃSKA nr 24A lok. 114 02-703 WARSZAWA POLSKA
UNITED AIRLINES, INC. (UA) - z siedzibą w Chicago (233 S. Wacker Drive, Chicago, IL 60606, United States)
VOYAGE AIR (VO) - OFFICE Varna, Bulgaria Address: Varna 9000, 1 Bacho Kiro str., Office 1-2 Phone: +359/52 602 622 Email: charter@vgrflight.com OFFICE Sofia, Bulgaria Address: Sofia, 96 Rakovsky str., fl.3 e-mail: charter@vgrflight.com
VUELING AIRLINES (VY / VLG) - z siedzibą w Viladecans Business Park, Edif. Brasil, Carrer de Catalunya, 83, 08840 Viladecans (Barcelona), Hiszpania
WIZZ AIR ABU DHABI L.L.C. (5W / WAZ) - Business Park 01, Plot P6, Office number 208, Abu Dhabi International Airport, Abu Dhabi, United Arab Emirates
WIZZ AIR Hungary Ltd. (W6 / WZZ) - Oddział w Polsce ul. Wolności 90 42-625 Pyrzowice
WIZZ AIR MALTA LIMITED (W4/WMT) - Skyparks Business Centre, Level 2, Malta International Airport, Luqa LQA 4000, Malta
WIZZ AIR UK (W9; WUK) - Percival House 134 Percival Way, London Luton Airport Roundabout, Luton, United Kingdom LU2 9NU
2.8.
Flight no. (a separate application must be submitted for each disrupted flight)
2.10.
Date of the flight
2.9.
Reservation no. (fill olny if no flight number)
Departure took place:
from Poland
from another EU country, Norway, Switzerland or Iceland
from a country outside the EU
The arrival took place:
to the airport in Poland
to the airport of EU, Norway, Switzerland, Iceland
to an airport in a non-EU country
2.11.
Departure airport
2.12.
Arrival airport
2.13.
Scheduled time of the departure
2.14.
Actual time of the departure
2.15.
Scheduled time of the arrival
2.16.
Actual time of the arrival
2.17.
Transit airports (if applicable)
2.18.
Airport / airports where the event took place Proceedings concerning disputes arising from the Regulation No 261/2004/EC are related to flights from airports located on the territory of the Republic of Poland serviced by the EU air carriers as well as flights from third countries to these airports serviced by the EU air carriers.
Has the Applicant/Passenger already submitted an application to the Ombudsman in the same case?
YES
NO
Is the new application a supplement (extension) to the previous application?
YES
NO
3.
Type of proceedings
I request initiating the proceedings consisting in reconciliation of positions in order to resolve my dispute.
4.
The dispute concerns:
cancellation of the flight
delay of the flight
denied boarding
upgrade
downgrade
no care provided
no information about passenger’s rights
others claims from regulations 261/2004/WE or regulations 2111/2005/WE
5.
I was informed about the cancellation or delay of the flight or another specified incident:
When were you informed about the cancellation or delay or another specified incident?
at the airport
less than 7 days before the flight scheduled
between 7 and 14 days before the flight scheduled
more than 14 days before the flight scheduled
Is the subject of the dispute only a claim for damages under Regulation 261/2004/WE?
YES
NO
6.
What was the reason given for the flight cancellation or delay?
7.
An accurately specified demand and description of the circumstances justifying the demand
(state the proposal for solution this dispute and write what exactly happened)
I request a payment of compensation according to Regulation (EC) No 261/2004
I request reimbursement of expenses in the amount of
PLN
EUR
USD
AFN
ALL
ANG
ARS
AUD
AWG
AZN
BAM
BBD
BGN
BMD
BND
BOB
BRL
BSD
BWP
BYR
BZD
CAD
CHF
CLP
CNY
COP
CRC
CUP
CZK
DKK
DOP
EGP
FJD
FKP
GBP
GGP
GHC
GIP
GTQ
GYD
HKD
HNL
HRK
HUF
IDR
ILS
IMP
INR
INR
IRR
ISK
JEP
JMD
JPY
KGS
KHR
KPW
KRW
KYD
KZT
LAK
LBP
LKR
LRD
LTL
LVL
MKD
MNT
MUR
MXN
MYR
MZN
NAD
NGN
NIO
NOK
NPR
NZD
OMR
PAB
PEN
PHP
PKR
PYG
QAR
RON
RSD
RUB
SAR
SBD
SCR
SEK
SGD
SHP
SOS
SRD
SVC
SYP
THB
TRL
TRY
TTD
TVD
TWD
UAH
UYU
UZS
VEF
VND
XCD
YER
ZAR
ZWD
in case of lack of the assistance according to Regulation (EC) No 261/2004
I request reimbursement
PLN
EUR
USD
AFN
ALL
ANG
ARS
AUD
AWG
AZN
BAM
BBD
BGN
BMD
BND
BOB
BRL
BSD
BWP
BYR
BZD
CAD
CHF
CLP
CNY
COP
CRC
CUP
CZK
DKK
DOP
EGP
FJD
FKP
GBP
GGP
GHC
GIP
GTQ
GYD
HKD
HNL
HRK
HUF
IDR
ILS
IMP
INR
INR
IRR
ISK
JEP
JMD
JPY
KGS
KHR
KPW
KRW
KYD
KZT
LAK
LBP
LKR
LRD
LTL
LVL
MKD
MNT
MUR
MXN
MYR
MZN
NAD
NGN
NIO
NOK
NPR
NZD
OMR
PAB
PEN
PHP
PKR
PYG
QAR
RON
RSD
RUB
SAR
SBD
SCR
SEK
SGD
SHP
SOS
SRD
SVC
SYP
THB
TRL
TRY
TTD
TVD
TWD
UAH
UYU
UZS
VEF
VND
XCD
YER
ZAR
ZWD
of unused airplane ticket according to Regulation (EC) No 261/2004
I request (indicate the amount and substantiation) – another claims under Regulation 261/2004/WE or 2111/2005/WE in the amount:
PLN
EUR
USD
AFN
ALL
ANG
ARS
AUD
AWG
AZN
BAM
BBD
BGN
BMD
BND
BOB
BRL
BSD
BWP
BYR
BZD
CAD
CHF
CLP
CNY
COP
CRC
CUP
CZK
DKK
DOP
EGP
FJD
FKP
GBP
GGP
GHC
GIP
GTQ
GYD
HKD
HNL
HRK
HUF
IDR
ILS
IMP
INR
INR
IRR
ISK
JEP
JMD
JPY
KGS
KHR
KPW
KRW
KYD
KZT
LAK
LBP
LKR
LRD
LTL
LVL
MKD
MNT
MUR
MXN
MYR
MZN
NAD
NGN
NIO
NOK
NPR
NZD
OMR
PAB
PEN
PHP
PKR
PYG
QAR
RON
RSD
RUB
SAR
SBD
SCR
SEK
SGD
SHP
SOS
SRD
SVC
SYP
THB
TRL
TRY
TTD
TVD
TWD
UAH
UYU
UZS
VEF
VND
XCD
YER
ZAR
ZWD
8.
Information on the existing passenger dispute
(describe, for example, whether you made a complaint to the carrier, what was the complaint process, whether you received a response and what was it)
Have passengers exhausted the complaint procedure in this case?
The complaint procedure is considered exhausted if the air carrier, tour operator or ticket seller considered the complaint or the deadline for its consideration has expired. If the air carrier, tour operator or ticket seller has not responded to the complaint within 30 days from the date of its submission, it is considered that the complaint has been accepted.
YES
NO
The complaint was submitted on
I received a response from the carrier (or in the case of claims under 2111/2005/WE, the tour operator or ticket seller) on
To date, I have not received a response from the carrier (or in the case of claims under 2111/2005/WE, the tour operator or ticket seller)
Additional information:
9.
Indicate whether the flight was directly related to economic or professional activity of the passenger/passengers
private flight
flight was directly related to the economic or professional activity
10.
Attachments
(attach copies of documents confirming the information contained in the application, e.g. copies of tickets, reservation, complaint made, entrepreneur’s response to the complaint, copy of the correspondence with the entrepreneur if the application is submitted by an authorised attorney or another passenger, original or copy of the power of attorney, birth certificate in case of a minor passenger)
copy/scan/hard copy of a ticket or reservation for a given flight
Send file
Stop sending
Files .pdf .doc .docx .tiff .tif .jpg
copy/scan/hard copy of a complaint
Send file
Stop sending
Files .pdf .doc .docx .tiff .tif .jpg
copy/scan/hard copy of a response to a complaint
Send file
Stop sending
Files .pdf .doc .docx .tiff .tif .jpg
copy/scan/hard copy of the correspondence exchanged with the entrepreneur
Send file
Stop sending
Files .pdf .doc .docx .tiff .tif .jpg
copy/scan/master copy of the power of attorney – also if one passenger submits the application on behalf of the other passengers
Send file
Stop sending
Files .pdf .doc .docx .tiff .tif .jpg
copy/scan/original of the statement on the statutory representation of the statutory representatives of the underage passenger
Send file
Stop sending
Files .pdf .doc .docx .tiff .tif .jpg
declaration concerning statutory representation
Send file
Stop sending
Files .pdf .doc .docx .tiff .tif .jpg
other (specify):
Send file
Stop sending
Files .pdf .doc .docx .tiff .tif .jpg
11.
I declare that:
I have read the Rules and regulations of the out-of-court passenger dispute resolution by the Passengers’ Rights Ombudsman at the President of the Civil Aviation Authority and I have accepted conditions thereof (https://pasazerlotniczy.ulc.gov.pl/upload/Regulaminy/REGULATIONS_ADR_ENG_1.1.2024.pdf). I know that the Ombudsman will refuse to consider a civil law dispute when the passenger’s application concerns flights other than: - flights from airports located on the territory of the Republic of Poland or - flights from third countries to airports located on the territory of the Republic of Poland serviced by Community air carriers where, determined pursuant to Article 16(1) of the Regulation (EC) No 261/2004, the competence of authority is the authority of another Member State or Switzerland, Norway, Iceland. I acknowledge that due to the large number of applications submitted to the Ombudsman, the waiting time for application consideration is extended, applications are considered in the order in receiving.
I attempted to contact the other party and sought a direct passenger dispute resolution on (e.g. the date of submitting a complaint to the carrier):
the case concerning the same claim between the same parties is not pending and it has not been already considered by other competent entity or by the court, (Remember that if in the same case you have brought an action against the entrepreneur before the court or the proceedings in the case are pending before the Ombudsman or other body authorised to amicably resolve disputes, the Ombudsman will be obliged to refuse to consider the dispute)
I hereby declare that I (the applicant)and each of Passengers, on behalf of whom I am submitting this application, have been informed about the objective of and legal basis for processing my personal data by the President of the Civil Aviation Authority based, at 2 M. Flisa Street, 02-247 Warsaw, contained in the application for the initiation of proceedings before the Passenger Rights Ombudsman in order to conduct these proceedings. (
link to the INFORMATION CLAUSE
)
Passenger's claim has not been transferred to another entity (e.g. by an assignment, trustee transfer agreement, etc.)
I obligate to inform the Passengers' Rights Ombudsman if the dispute is resolved before the ADR procedure is initiated.
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