Annex III MODEL FORM FOR THE SUBMISSION OF COMMUNICATIONS UNDER THE OPTIONAL PROTOCOL TO THE CONVENTION ON THE RIGHTS OF PERSONS WITH DISABILITIES I. Information concerning the author(s) of the communication • Family name: ............................................................................. • First name: ................................................................................ • Date and place of birth:............................................................... • Nationality/citizenship: ............................................................... • Sex: ......................................................................................... • Other relevant personal identification data (if any of the above details are not available): ............................................................................ .............................................................................................. .............................................................................................. • Present address: ......................................................................... .............................................................................................. .............................................................................................. • Postal address for confidential correspondence (if other than present address): ............................................................................................... .............................................................................................. • Telephone or mobile number (if any): .............................................. • E-mail address (if any):................................................................. • Fax number (if any): .................................................................... • If you are submitting the communication on behalf of the alleged victim(s), please provide evidence of the consent of the victim(s), or reasons that justify submitting the communication without such consent:................... .............................................................................................. .............................................................................................. .............................................................................................. 32