‘ANNEX IISINGLE DOCUMENT

Date of receipt (DD/MM/YYYY) …

[to be completed by the Commission]

Number of pages (including this page) …

Language used for submission of application …

File number [to be completed by the Commission] …

Applicant

Name of legal or natural person …

Full address (street number and name, town/city and postal code, country) …

Legal status (in the case of legal persons) …

Nationality …

Intermediary

• Member State(s) (*) …

• Third-country authority (*) …

[(*) delete as appropriate]

Name(s) of intermediary(ies) …

Full address(es) (street number and name, town/city and postal code, country) …

Name to be registered

• Designation of origin (*) …

• Geographical indication (*) …

[(*) delete as appropriate]

Description of the wine(s)11 …

Indication of traditional terms, as referred to in Article 118u(1)12, which are linked to this designation of origin or geographical indication …

Specific oenological practices13 …

Demarcated area …

Maximum yield(s) per hectare …

Authorised wine grape varieties …

Link with the geographical area14 …

Further conditions13 …

Reference to product specification