xmlns:atom="http://www.w3.org/2005/Atom" xmlns:atom="http://www.w3.org/2005/Atom"
Member State(s) (*)
Third-country authority (optional) (*)
[(*) delete as appropriate]
Name(s) of intermediary(ies) …
Full address(es) (street number and name, town/city and postal code, country) …