Annex I MODEL FORM FOR THE SUBMISSION OF COMMUNICATIONS UNDER THE OPTIONAL PROTOCOL TO THE INTERNATIONAL COVENANT ON CIVIL AND POLITICAL RIGHTS, THE CONVENTION AGAINST TORTURE OR THE INTERNATIONAL CONVENTION ON THE ELIMINATION OF ALL FORMS OF RACIAL DISCRIMINATION Please indicate which of the above procedures you are invoking: ............. .................................................................................................... Date: ............................................................................................ I. Information on the complainant Name: ................................First name(s): ........................................ Nationality: ..........................Date and place of birth: ......................... Address for correspondence on this complaint: ...................................... .................................................................................................... .................................................................................................... Submitting the communication: on your own behalf F or on behalf of another person F If the complaint is being submitted on behalf of another person, please provide the following details of that other person: Name: ................................First name(s): ........................................ Nationality: ..........................Date and place of birth: ......................... Address or current whereabouts: ........................................................ .................................................................................................... .................................................................................................... If you are acting with the knowledge and consent of that person, please provide that person’s authorization for you to bring this complaint .................................................................................................... Or If you are not so authorized, please explain the nature of your relationship with that person: ............................................................................. .................................................................................................... and detail why you consider it appropriate to bring this complaint on his or her behalf: ..................................................................................... .................................................................................................... 25