ANNEX II
Template for the insider list to be submitted by issuers of financial instruments admitted to trading on SME growth markets
Date and time (creation): [yyyy-mm-dd, hh:mm UTC (Coordinated Universal Time)]
Date of transmission to the competent authority: [yyyy-mm-dd]
First name(s) of the insider | Surname(s) of the insider | Birth surname(s) of the insider (if different) | Professional telephone number(s) (work direct telephone line and work mobile numbers) | Company name and address | Function and reason for being insider | Obtained (the date and time at which a person obtained access to inside information) | Ceased (the date and time at which a person ceased to have access to inside information) | National Identification Number (if applicable) Or otherwise date of birth | Personal full home address (street name; street number; city; post/zip code; country) (If available at the time of the request by the competent authority) | Personal telephone numbers (home and personal mobile telephone numbers) (If available at the time of the request by the competent authority) |
[Text] | [Text] | [Text] | [Numbers (no space)] | [Address of issuer or third party of insider] | [Text describing role, function and reason for being on this list] | [yyyy-mm-dd, hh:mm UTC] | [yyyy-mm-dd, hh:mm UTC] | [Number and/or text or yyyy-mm-dd for the date of birth] | [Text: detailed personal address of the insider Street name and number City Post/zip code Country] | [Numbers (no space)] |