Annex II MODEL FORM FOR THE SUBMISSION OF COMMUNICATIONS UNDER THE OPTIONAL PROTOCOL OF THE CONVENTION ON THE ELIMINATION OF ALL FORMS OF DISCRIMINATION AGAINST WOMEN I. Information concerning the author(s) of the communication • Family name: ............................................................................. • First name: ................................................................................ • Date and place of birth:............................................................... • Nationality/citizenship: ............................................................... • Passport/identity card number (if available): .................................... • Sex: ......................................................................................... • Marital status/children:................................................................ • Profession:................................................................................. • If relevant, ethnic background, religious affiliation, social group:................. • Present address: ......................................................................... ............................................................................................... • Postal address for confidential correspondence (if other than present address): ...................................................................................... ............................................................................................... ............................................................................................... • Telephone number/e-mail address: ................................................ • Indicate whether you are submitting the communication as:................. Alleged victim(s). If there is a group of individuals alleged to be victims, provide basic information about each individual.  F  F On behalf of the alleged victim(s). Provide evidence of the consent of the victim(s) or reasons that justify submitting the communication without such consent. 28