Statement for tax and insurance purposes to the Contract of Mandate

1. Personal data

2. Residential address

Label

3. Mailing address

Label

Correspondence address the same as residence

4. Internal Revenue Service

Competent to provide annual information on income and collected advances for income tax PIT-11

5. Declaration for the purposes of universal health insurance

I'm a pensioner

I am a pensioner:

I have a disability certificate

7. Statement to the District Employment Office

I declare that:

I remain

I don't stay

in the register of the unemployed kept by the District Labour Office in:

8. Declaration for the purposes of voluntary social/sickness insurance

I propose
I don't bring

for me to be covered by voluntary retirement and disability/sickness insurance

9. Person to be notified in the event of an accident

10. Additional Information

E.g. school completed, qualifications, specialization

11. Statement on the centre of vital interests

I declare that my center of vital interests is located in Poland:

12. Additional Consents and Representations

I declare that all the information provided is consistent with the factual and legal status, and I am aware of the criminal liability for providing false information or concealing it. I undertake to inform the Principal in writing within 5 days from the date of occurrence of any changes to the content of this statement and I assume responsibility for failure to comply with the above obligation. I authorize the Principal to register for health and/or social insurance on my behalf, provided that the performance of the mandate contract by me is subject to such insurance in accordance with the applicable regulations. In the event of providing incorrect information, as well as in the event of failure to provide information about the change of data that affect the payment of contributions, I undertake to return to the payer the social security contributions (pension, disability pension) financed from the funds of the insured and the Principal paid by him to the Social Insurance Institution and the interest on the entire debt.
I consent to the processing of my products by ECOTEC POLSKA Sp. z o.o., ECOTEC DEUTSCHLAND GmbH and ECOTEC AUSTRALIA Pty Ltd. personal data and documents provided by me for the purposes specified in the information clause below.

INFORMATION CLAUSE

In accordance with Article 13 of the Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (Official Journal of Laws of the Republic of Poland). UE L 119 of 04.05.2016, p. 1, with the amendment announced in the Official Journal of the European Union. UE L 127 of 23.05.2018, p. 2), hereinafter referred to as the “Regulation”, we inform you that the Controller of your personal data, hereinafter referred to as the “Controller”, is Ecotec Polska Sp. z o.o. with its registered office: 02-229 Warsaw, ul. World 22. Contact with the Administrator is possible at the e-mail address: gdpr@ecotec-polska.pl and correspondence address: 02-229 Warsaw, ul. World 22. Your personal data will be processed:

to identify the parties to the contract for the provision of services
in order to conclude and terminate the contract for the provision of
for purposes related to the calculation of taxes and reporting to the Social Insurance Institution (if required)
for the purpose of demonstrating (by the Administrator, other entities in the “group of enterprises” to which the Administrator belongs and by entities related to the services performed, including recipients of services) compliance with national law, in particular, but not limited to, provisions concerning: required competences, health and safety, lack of contraindications to perform a given scope of work, provisions concerning the contract of mandate, (minimum) remuneration and other benefits resulting from the contract, legality of employment, compliance with the obligation to pay contributions in social security systems, posted persons, legality of stay, legality of work (abroad);
for the purposes resulting from the legitimate interests pursued by the Administrator or by a third party, in particular, but not exclusively, for the purpose of pursuing claims or protecting against claims.

The legal basis for the processing is:

Art. 6 sec. 1 lit. b) the Regulation, i.e. “the data subject is a party to the contract” and Art. 6 sec. 1 lit. a) the Regulation, i.e. “consent of the individual to the processing of his or her personal data” in connection with the requirements of Regulation (EC) No. 883/2004 of the European Parliament and of the Council of 29 April 2004. on the coordination of social security systems and Regulation (EC) No 987/2009 of the European Parliament and of the Council of 16 September 2009. Regulation (EC) No 883/2004.

Your personal data may be disclosed to the following categories of recipients:

employees and associates of the Administrator, entities in the “group of enterprises” (in the Ecotec group), and entities related to the services provided (including recipients of services),
the administrator’s clients, other contractors of the administrator,
entities providing the Administrator with consulting, legal, tax, accounting and HR services, health and safety services,
entities providing technical support services to the Administrator and providers of IT solutions enabling the Administrator’s business (e.g. software providers, e-mail and hosting providers),
Polish public authorities acting on the basis of applicable law,
foreign government and local government bodies and other authorities and institutions of the posting country according to territorial or objective jurisdiction, respectively these may be, for example, social security institutions, institutions monitoring compliance with the national laws specified above, consular authorities, institutions for social security and foreigners, the Police, institutions responsible for border protection, customs and tax institutions, ministries competent in matters of employment, and other entities authorized to obtain personal data on the basis of legal provisions,
if the contract is concluded using the Autenti system, the personal data contained in the contract will be processed (stored) by Autenti sp. z o.o. with its registered office in Poznań, at ul. St. Marcin 29/8, 61-806 Poznań, whose privacy policy is available at https://autenti.com/regulaminy/polityka-ochrony-prywatnosci-autenti/.

Your personal data will be processed only for the period necessary and specified in the provisions of law. You have the right to access your personal data, rectify it, delete it or limit its processing, object to the processing, as well as the right to transfer data. The provisions of the Regulation indicate to what extent each of these rights can be exercised. This will depend in particular on the legal basis and purpose of the processing of personal data by the Administrator. You have the right to lodge a complaint with the supervisory authority, i.e.: President of the Office for Personal Data Protection. Providing personal data is a contractual requirement and a condition for concluding a contract. You are obliged to provide them, and failure to provide data will result in the inability to conclude a contract. Personal data will not be used for automated decision-making that has legal effects on you, including profiling.

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