Form Eu4 – Fill Out and Use This PDF

DEPARTMENT OF JUSTICE AND EQUALITY	FORM EU 4
IRISH NATURALISATION & IMMIGRATION SERVICE
Re qu e st f or Re v ie w of D e cision		1 0 / 2 0 1 2

For EU1, EU2 or EU3 Applicant

This for m is t o be com plet ed by each per son r equest ing a r ev iew under Regulat ion 21 of t he Eur opean Com m unit ies ( Fr ee Mov em ent of Per sons) Regulat ions 2006 and 2008 .

• I f y ou ar e unable t o pr ovide any of t he inform at ion or det ails r equest ed in any of t he r elev ant sect ions, please explain t he reasons in a let t er and enclose it wit h t his applicat ion for m .

1 . 1 Applicant Per son I D Num ber

1 . 2 Applicat ion I D Num ber

2 . 1

Nam e ( as in passpor t )

2 . 2

Dat e of Bir t h

2 . 3 Gender ( please t ick )

2 . 4 PPS Num ber

Male

Fem ale

Day

Mon t h

Year

2 . 5

Nat ionalit y

2 . 6

Cur r ent Resident ial Addr ess in I r eland

2 . 7 Relat ionship t o EU cit izen ( f or r ev iew of EU1 or EU3 only )

Spouse

Par t ner

Div or ced/ Annulled

Ot her fam ily dependant

Par ent

Sibling

Child

I f " Ot her fam ily dependant " , please specify :

For m EU4 ( 10/ 2012) - Page 1 of 4

2 . 8 Cont act Telephone Num ber

2 . 9 Em ail Addr ess

3 . 1

Nam e ( as in passpor t )

3 . 2

Dat e of Bir t h

3 . 3 Gender ( please t ick )

3 . 4 PPS Num ber

Male

Fem ale

Day

Mont h

Year

3 . 5

Cur r ent Resident ial Addr ess in I r eland

3 . 6 Nat ionalit y

3 . 7 Cont act t elephone num ber

3 . 8 Em ail Addr ess

For " D e t a ils of cu r r e n t a ct iv it y " in t his sect ion, please pr ov ide t he follow ing as applicable: nam e and addr ess of w or k place; nam e and addr ess of business; addr ess of college and cour se t it le; t ype of Social Welfar e r eceiv ed; det ails of r esour ces ( e. g. pension) .

4 . 1 Ty pe of act iv it y ( please t ick )					4 . 3 Det ails of cur r ent act iv it y
		Em ploym ent		St udy

Inv olunt ar y Unem ploym ent

4 . 2 Dat e of com m encem ent of act iv it y

Day

Mont h

Year

5 . 1 Nam e of legal r epr esent at iv e

5 . 2 Addr ess of legal r epr esent at iv e

5 . 3 Aut hor isat ion by applicant

I her eby aut hor ise t he afor em ent ioned legal r epr esent at iv e t o act on m y behalf for m at t er s r elat ing t o t his r ev iew applicat ion .

Sign e d by a p p lica n t

D a t e

Day

Mon t h

Year

For m EU4 ( 10/ 2012) - Page 2 of 4

6 . 1 St at em ent of t he gr ounds on w hich t he r equest er seek s t he r ev iew of t he decision m ade ( indicat ing w her e, in t he v iew of t he r equest er , t he deciding officer er r ed in fact and/ or in law )

6 . 2 Any addit ional st at em ent s w hich t he r equest er w ishes t o be consider ed

6 . 3 Addit ional docum ent at ion w hich t he r equest er w ishes t o be consider ed

i.

ii.

iii.

iv.

v .

For m EU4 ( 10/ 2012) - Page 3 of 4

Applicant

For a r e v ie w of a n a pplica t ion m a d e on For m EU 1 , EU 2 or EU 3 , t h is d e cla r a t ion sh ou ld b e sig n e d a n d d a t e d b y t h e a pplica n t or by t h e pa r e n t or gu a r dia n of a n a p plica n t u n de r t h e a g e of 1 8 .

The infor m at ion

I hav e

giv en

is com plet e and is t r ue

t o t he

best

of

m y k now ledge. I also

declar e t hat t he

phot ogr aphs

subm it t ed

w it h

t his for m

ar e

a

t r ue lik eness of

m e. I

confir m

t hat

if,

befor e m y applicat ion

is decided,

t her e

is a m at er ial

change in

m y

cir cum st ances or

new

infor m at ion

r elev ant

t o t his applicat ion becom es av ailable, I w ill infor m t he EU Tr eat y

Right s Sect ion

of t he Depar t m ent of

Just ice and Equalit y

in w r it ing im m ediat ely . I under st and t hat any

false or m isleading

infor m at ion or fr audulent suppor t ing docum ent at ion subm it t ed w ill r esult in t he r efusal of t his applicat ion .

I under st and

t hat , under Sect ion 8

of t he I m m igr at ion

Act 2003

and Regulat ion 1 9 of t he

Eur opean

Com m unit ies ( Fr ee

Mov em ent of Per sons) Regulat ions 2006 and 2008, t he dat a in t his applicat ion m ay be disclosed t o ot her I r ish Gov er nm ent Depar t m ent s as w ell as t o public aut hor it ies of t he Mem ber St at es of t he Eur opean Union and Eur opean Econom ic Ar ea ( EEA) for pur poses connect ed t o t his applicat ion . I consent t o t he EU Tr eat y Right s Sect ion m ak ing enquir ies t o confir m any of t he det ails or docum ent s pr ov ided by m e in t his applicat ion, including m y par t icipat ion in an int er v iew pr ocess.

I am aw ar e t hat a per son w ho asser t s an ent it lem ent t o any r ight s on t he basis of infor m at ion w hich he or she k now s t o be false or m isleading in a m at er ial par t icular shall be guilt y of an offence and shall be liable on sum m ar y conv ict ion t o a fine not ex ceeding € 5,000 or t o a t er m of im pr isonm ent not ex ceeding 12 m ont hs, or bot h .

Sign e d by a p plica n t	D a t e
		Day			Mon t h				Year

EU Cit izen

For a r e v ie w of a n a p p lica t ion m a d e on For m EU 1 or EU 3 , t h is d e cla r a t ion sh ou ld b e sig n e d a n d d a t e d b y t h e Eu r op e a n U n ion , EEA or Sw iss cit iz e n of w h om t h e a pplica n t is a f a m ily m e m be r .

The infor m at ion giv en in t his for m is com plet e and is t r ue t o t he best of m y k now ledge. I also declar e t hat t he phot ogr aphs subm it t ed w it h t his for m ar e of a t r ue lik eness of m e. I confir m t hat if, befor e t he applicat ion is decided, t her e is a m at er ial

change in m y	cir cum st ances or new	infor m at ion r elev ant	t o t his applicat ion becom es av ailable, I w ill infor m t he EU Tr eat y
Right s Sect ion	of t he Depar t m ent of	Just ice and Equalit y	in w r it ing im m ediat ely . I under st and t hat any	false or m isleading
infor m at ion or	fr audulent suppor t ing docum ent at ion subm it t ed w ill r esult in t he r efusal of t his applicat ion .
I under st and	t hat , under Sect ion 8	of t he I m m igr at ion	Act 2003 and Regulat ion 1 9 of t he Eur opean	Com m unit ies ( Fr ee

Mov em ent of Per sons) Regulat ions 2006 and 2008, t he dat a in t his applicat ion m ay be disclosed t o ot her I r ish Gov er nm ent Depar t m ent s as w ell as t o public aut hor it ies of t he Mem ber St at es of t he Eur opean Union and Eur opean Econom ic Ar ea ( EEA) for pur poses connect ed t o t his applicat ion . I consent t o t he EU Tr eat y Right s Sect ion m ak ing enquir ies t o confir m any of t he det ails or docum ent s pr ov ided by m e in t his applicat ion, including m y par t icipat ion in an int er v iew pr ocess.

I am aw ar e t hat a per son w ho asser t s an ent it lem ent t o any r ight s on t he basis of infor m at ion w hich he or she k now s t o be false or m isleading in a m at er ial par t icular shall be guilt y of an offence and shall be liable on sum m ar y conv ict ion t o a fine not ex ceeding € 5,000 or t o a t er m of im pr isonm ent not ex ceeding 12 m ont hs, or bot h .

Sign e d by Eu r op e a n U n ion , EEA or Sw iss Cit iz e n	D a t e
		Day			Mon t h				Year

Please r et ur n com plet ed for m s and or iginal docum ent s by r egist er ed post t o:

EU Tr e a t y Righ t s Re v ie w U n it

Ir ish N a t u r a lisa t ion & I m m igr a t ion Se r v ice D e pa r t m e n t of Ju st ice a n d Equ a lit y

1 3 / 1 4 Bu r g h Qu a y D u b lin 2

For m EU4 ( 10/ 2012) - Page 4 of 4