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Granting of partially refundable aid for the development of a new quarterly formulation of Risperidone

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OFFICE MADRID

Calle José Isbert, 2.
28223 Pozuelo de Alarcón (Madrid) - España
Tel: (+34) 91 021 30 00 email: rovi@rovi.es

OFFICE BARCELONA

Travesera de Gracia, 415-417.
08025 Barcelona - España

OFFICE FRANCIA

Rue du Drac, 24.
38180 Seyssins. France

OFFICE ALEMANIA

Rudolf-Diesel-Ring, 6.
83607 Holzkirchen. Germany

OFFICE ITALIA

Viale Achille Papa, 30.
20149 Milano. Italy

OFFICE UNITED KINGDOM

Davis House, 4th floor, Suite
425, Robert Street CR0 1QQ
Croydon. England

OFFICE PORTUGAL

Alameda Fernão Lopes 16, 12º direito
1495-190 Algés
Portugal
Tel: (00351) 21 310 56 10
email: geral@rovi.com

Map

PRIVACY POLICY
TERMS AND CONDITIONS
LEGAL NOTICE
COOKIE POLICY
EXERCISE OF RIGHTS GDPR

Copyright © 2017 Laboratorios Farmaceuticos ROVI SA - All rights reserved

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INFORMATION ON PERSONAL DATA PROTECTION

Pursuant to Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, we set out below the basic information on the processing of your personal data obtained through this website (hereinafter, the “Website”).

Basic information on data protection

Controller: Laboratorios Farmacéuticos ROVI, S.A., hereinafter the Company. See general information in the full privacy policy.
Postal address: Julián Camarillo, 35, 28037 Madrid.
Telephone: 91 375 62 30
Email: protecciondedatos@rovi.es

Purpose: To allow access to the Website and its content and functionalities, manage and optimise the Website and safeguard its security and integrity to ensure its proper functioning and the security of the network and information; to process and respond to requests, applications, incidents or queries from Users, tracking and analysing them for statistical purposes and processing and managing the job applications received.

Legal basis: The Company’s legitimate interests, precontractual measures.

Rights: The rights of access to and rectification or erasure of personal data, data portability and the restriction of processing, as well as the right to object and other legally-recognised rights, may be exercised at any time by contacting the Company at the address given in the "Controller” section above.

Additional information: We invite you to read our Privacy Policy below for a detailed understanding of the use we will make of your personal data and the rights you hold in relation thereto.

This Privacy Policy contains all the information on the processing by Laboratorios Farmacéuticos ROVI, S.A. (hereinafter, “the Company·) of the personal data collected through this Website in relation to each user’s interaction with the Company, in accordance with the provisions of the General Data Protection Regulation.

For the purposes of this Policy,

User(s) will mean all persons who access, browse or use any of the functions available on this Website.

1. Who is the data controller?

You will find the registration and contact details of the company responsible for processing your personal data below, together with those of its Data Protection Officer (hereinafter, “DPO”).
• Name: Laboratorios Farmacéuticos ROVI, SA. (ROVI) – CIF: A-28041283
• Postal address: calle Julián Camarillo, 35- 28037 Madrid
• Telephone: 91 375 62 30
• Email: protecciondedatos@rovi.es

2. Who is the Data Protection Officer (DPO) and how can they help you?

The DPO is provided for by law and has the primary functions of informing and advising entities on the personal data obligations to which they are subject and supervising compliance with such obligations. Furthermore, the DPO acts as a contact point with entities for any issue concerning personal data processing and, therefore, you may contact them if you so wish.

DPO contact: dporovi@rovi.es

3. What personal data do we process

The Company processes the data provided by Users (hereinafter “the User” or “Users” without distinction) through the different forms and channels enabled on the Company’s website in order to respond to the User’s request, application or query, as well as the data obtained during browsing. However, we will only process the personal data provided for the purposes set out in this Privacy Policy.

Unless expressly stated otherwise, all the personal data requested on the forms enabled for data collection on the Website must be provided, since they are indispensable and, if you do not provide them, we will be unable to reply to your query, manage your job application or ensure the proper functioning of the Website. Therefore, Users must complete the fields marked “obligatory" on the forms on the different Websites since, otherwise, it may be impossible to provide the service requested or for the Website to function correctly.

If third-party data are provided, the User who provides said data guarantees that they were obtained and provided to the Company after the data subjects had been informed and had provided their consent, pursuant to data protection regulations. In this respect, the User will hold the Company harmless from and against any liability derived from non-compliance with this guarantee.

The User represents and warrants that the data provided is true and accurate and that said data reflect the current situation. In this respect, Users undertake to notify the Company of any change that may take place in the data provided, following the procedure set out in section 8 of this Privacy Policy.

4. For what purpose do we process your personal data? What is the legal basis for processing personal data?

The Company will process Users’ personal data for the following purposes:

• To allow access to the Website and its content and functionalities.

• To manage and optimise the Website and safeguard its security and integrity to ensure its proper functioning and the security of its network and information.

• To process and respond to Users’ requests, applications, incidents or queries when they provide their data through the forms enabled for this purpose on the Website. Likewise, they will be subsequently tracked and the information will be analysed for statistical purposes.

The legal basis for the data processing is the Company’s legitimate interest in the purposes mentioned above.

• To process and manage job applications received through the Website.

The legal basis for the data processing is the execution of precontractual measures.

• Communication to public authorities, regulators or government bodies.

5. For how long will be process your personal data?

The storage period of your data will be determined by the duration of your relationship with ROVI and the periods established by law. In this respect, the criteria ROVI uses to fix the storage periods of your data have been determined in accordance with the requirements set out in the applicable legislation, regulations and regulatory guidelines, as well as the operational requirements of ROVI related to proper management of the relationships that exist with data subjects.

The personal data provided will be retained unless the User requests the erasure of his or her personal data, provided, except when the data it is not necessary to process the data for the purposes described in this Policy.

In particular, personal data collected in order to attend to an application, query, request, incident or any other procedure that may be managed through the Website will be retained for the time necessary to attend to and resolve it.

When the periods mentioned above have elapsed and all the actions necessary to manage and extinguish the remaining obligations between the parties have been performed, the personal data will be erased. Notwithstanding the foregoing, the data will be retained, duly blocked, for the time necessary to comply with any legal obligation or to submit, exercise and/or defend any claims that may arise from the data processing.

6. To whom will we communicate your personal data?

The Company may communicate your personal data to the public authorities, regulators, government bodies or courts when thus required by law or local regulations or in compliance with regulatory obligations.

Apart from the aforementioned communication of data, the Company collaborates with certain external service providers who have access to your personal data and process said data in the name and on behalf of the Company as the result of a service provision.

The Company follows strict service supplier selection criteria to meet its data protection obligations and signs the pertinent data processing contract with said suppliers.

7. Do international data transfers exist’

The Company may have third-party collaborators or service providers located outside the territory of the European Union or the European Economic Area (EEA). In such cases, the Company adopts the appropriate legal guarantees to allow said transfers to be performed in accordance with current data protection regulations.

A copy of the measures required by the Company may be obtained by contacting the Data Protection Officer.

Likewise, the Company may transfer the personal data mentioned to other ROVI Group companies for the purposes of internal administration or economic/financial management.

All the ROVI Group companies are in the European Union except those in the United Kingdom and Switzerland, which have European Commission adequacy decisions.

8. What are your rights when you provide us with your personal data?

Users may exercise their right of access to their personal data and request inaccurate data be rectified or, if applicable, erased. They may also request the restriction of processing and data portability and may object to the processing of their data.

The User may exercise said rights, in the terms provided for in current legislation, by contacting the Company or through the supervisory authority of the Member State or the Agencia Española de Protección de Datos (Spanish Data Protection Agency), or by sending an email to protecciondedatos@rovi.es.

When the User sees fit, especially in the event that they do not receive a satisfactory reply, they may file a complaint with the Company, whose contact data are provided above.

9. Contact details of the Company’s DPO

In the event of any queries or questions regarding personal data processing by the Company, the User may contact the Company’s Data Protection Officer at the following email address: dporovi@rovi.es

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TERMS AND CONDITIONS

1.- These Terms and Conditions of Use set the rules to which the use of this Website's Contents are subject (hereinafter, the "Contents"). By accessing, downloading or using the Contents, you are considered a User, and said actions imply acceptance of all the terms and conditions contained in this document, in the Website's Privacy Policy and Legal Notice. The User must read these conditions each time he/she accesses, downloads or uses the Contents, as they may be modified in the future.

2.- Certain sections of the Rovi websites have been designed for specific audiences including the general public, healthcare professionals, shareholders of ROVI, etc.
When the Website is directed to healthcare professionals, a specific mention will be made.
Within the various services included in the Rovi websites, is to provide information on ROVI activities, products, health information and the health field. While some medical information may appear in the ROVI websites, if you are in a medical process, please refer to your doctor or to your healthcare provider. We do not offer personalized medical diagnosis or specific medical advice for patients.

3.- The Contents, as well as trademarks and other distinctive marks that appear therein, are the property of their respective holders or of Laboratorios Farmacéuticos Rovi, S.A. (hereinafter, "Rovi"). Users can access the Contents for consultation or for downloading in accordance with the conditions set out in this document. To this end, a content use license, non – exclusive and royalty free, is recognize to the user for medical and educational purposes. Such content use license is granted with the same terms and conditions for Contents updated and improvements. This license may be revoked unilaterally at any time, by merely notifying the User on this Web page.

It is prohibited to elude, disable or otherwise manipulate (or to attempt to elude, deactivate, or manipulate) the Website's security (or other) features, and to use the Contents for commercial or advertising purposes. Likewise, it is prohibited to use the Contents with the purpose of harming the assets, rights, or interests of Rovi, the authors or third parties.

4.- The User must refrain from: a) transforming or modifying the Contents; b) deleting or altering the author's name in the Contents; c) extracting or reusing all or a substantial part of the Contents in other works – unless express permission is granted by the author.

5.- The User commits to properly using the Contents in accordance with the law, these Terms and Conditions of Use, and any other regulations and/or instructions which may be of application. The User shall be held liable to Rovi, to the author, and to third parties for any losses or damages that may be caused by a failure to comply with these obligations.

6.- These Terms of Use are governed entirely by Spanish law. For the resolution of any disputes relating to their interpretation or application, the User expressly agrees to turn to the jurisdiction of the courts of Madrid (Spain).

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LEGAL NOTICE

1) This website web https://rovi.es/es is owned by the company Laboratorios Farmacéuticos ROVI, SA. (referred to hereinafter as “the Company”), with registered address in Julián Camarillo, 35- Steet 28037 Madrid with corporate identification number A- 28041283. Contact telephone number 91 375 62 30 and the e-mail address for these matters is protecciondedatos@rovi.es

The Company is a Pharmaceutical Laboratory authorized under Nº 2808E AEMPS.

To consult the codes of conduct adhered by the Company:

Código de Buenas Prácticas de la Industria

The use of this website attributes the condition of User to the visitor and implies the total acceptance of the provisions contained in the Privacy Policy, the Terms and Conditions and this Legal Notice.

2) The User must read these conditions every time when accessing this website, as these can be modified in the future. Certain aspects of the website , due to its specialty, may be subject to particular conditions or rules that could replace or modify this Legal Notice, and therefore should also be accepted by the User making use or accessing them.

3) In any case, it is prohibited to alter or modify any part of the website or its contents, elude, disable or manipulate in anyway (or trying to elude, disable or manipulate) the website ´s security features or other functions of the program and the use of the Web or its content for commercial or advertising purposes. You may not use this Website in a way that could damage the property, rights or interest of the Company or third parties. It is also prohibited to make any use of this Web that could alter, damage or affect networks, servers, equipments, products and software of the Company or third parties.

4) All the contents of this website (texts, photographs, graphics, images, technology, software, links, audiovisual contents or audios, graphic design, source code, etc.), as well as other trademarks and distinctive signs owned by the Company or third parties, not transferring to the User any right over them by the mere use of this website. The User must abstain from: a) reproduce, copy, distribute, make available to third parties, public communication, transform or modify the contents of this website , except in the cases referred in the law or expressly authorized by the Company or by the holder of such rights ; b) reproduce or copy for private use the software, images, videos or existing databases of this website , as well as publishing or making available to third parties when this involves reproduction; c) remove or reuse the contents included in this website.

5) It is not the Company´s responsibility controlling that this website there are no malware or harmful programs that may affect user´s computer. In any case, it is User´s responsibility to have the adequate tools for detection and disinfection of these items. Accordingly, the Company will not be liable for any damage produced to Users when such damages are originated in failures or disconnections in the telecommunication networks interrupting this website ´s service.

6) This website includes links that allow the User to access other webpages. In these cases, the Company shall only be liable for the contents and services provided through the links as soon as it is aware of their unlawfulness and has not diligently deactivated them If a User considers that there is a link with unlawful or inappropriate content, he will be able to inform the Company, not implying that the Company is obliged to remove the corresponding link. The Company is not always aware of the contents and services provided by the links and therefore is not responsible for any harm that may result due to the lack of quality, obsoleteness, unavailability, error, uselessness or illegality and does not respond to the statements made or contents or services provided by them, unless it is directly responsible for the provision of such services. If any user becomes aware that the links refer to pages whose contents or services are illicit, harmful, denigrating, violent or immoral, he/she may contact the Company indicating this.

7) The User undertakes to make proper use of this website, according to the Law, to this Legal Notice and the rest of conditions, rules and instructions that, in its case, could be applicable. The User will have to answer for any damage caused due to the non compliance to these obligations to the Company and third parties.

8) This Legal Notice is governed entirely by the spanish legislation. For the resolution of any dispute or interpretation of this Legal Notice, the User expressly submits himself to the Courts of his address.

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COOKIE POLICY

Laboratorios Farmacéuticos ROVI, S.A., (hereinafter, “the Company”) wishes to inform you that our website https://rovi.es/ (hereinafter the “Website”) uses cookies to ensure the website functions correctly and enhance browsing quality and accessibility.

What is a cookie?

A cookie is a file that is downloaded onto your computer when accessing certain websites. Cookies allow a website to, among other things, store and recover information on the browsing habits of a user or his or her computer and, depending on the information they contain, may be used to recognise the user.

However, cookies only obtain information related to the number of pages visited, the city to which the IP address from which the website is accessed is assigned, the number of new users, the frequency and recency of visits, the duration of visits, the browser or operator, or the type of terminal from which the visit is made.

We inform you that cookies do not damage or slow down your computer. Likewise, we inform you that you can delete them at any time or, in some cases, reject them by configuring the browsing software you use, as described below in this Policy.

These elements are intended to enhance your browsing experience, allow you to be recognised on future visits, store your preferences or browse more efficiently, swiftly and simply. The specific uses we make of this technology are described below.

Through cookies, the Company may collect your personal data (i.e. your IP address) and, therefore, through its Website, the Company provides information on the processing of your personal data in accordance with article 13 of the General Data Protection Regulation on the protection of natural persons with regard to the processing of personal data and on the free movement of such data.

Who is the data processor for the cookies on this Website?

The website owner and data controller for the cookies used here, together with their contact details, may be found in the Legal Notice on this Website. Likewise, there may be cookies belonging to third parties other than the website owner, as explained below.

What cookies does this Website use and what are they used for?

This Website uses first-party cookies the purposes of which are the communication between the user terminal and the network, establishing the User’s language and detecting acceptance of the use of cookies.

· Cookie SSESS is stored for 24 days.

· Cookie DRUPAL_UID is stored for 24 days.

· Cookie has_js stored during the session last.

· Cookie lng is stored for 24 hours.

· Cookie cookie-agreed is stored for 100 days.

What is the legal basis for the use of cookies?

In the case of technical cookies (those which are essential for browsing this Website and receiving the service it offers), the legal basis is the Company’s legitimate interest. For other types of cookie used on the Website, personalisation cookies, the legal basis is user consent.

To whom will the cookies be communicated or who may access them?

When third-party cookies exist, said third parties may access the cookies and use the data obtained to enhance their own services and offer services to other companies.

What are your rights in relation to this Website’s use of cookies?

Under current legislation, anybody is entitled to receive confirmation as to whether or not his or her personal data are being processed. Likewise, in the terms set out by law, data subjects have the right to access their data, request rectification of inaccurate data or, if applicable, request the data be erased when, among other reasons, the data are no longer necessary for the purposes for which they were collected. In the case of cookies, these rights may be exercised within the limitations derived from the nature of these files.

Under the conditions set out in the General Data Protection Regulation, data subjects may request the restriction of processing or the portability of their data, in which case we will only retain them for use in legal actions and/or exercising or defending claims.

In certain circumstances, for reasons concerning their specific situation, data subjects may object to the processing of their data. If you have granted consent for a specific purpose, you have the right to withdraw it at any time, although this will not affect the lawfulness of the processing based on consent before its withdrawal. In these cases, we will cease to process the data or, where applicable, will cease to process them for that specific purpose, except for overriding legitimate purposes or to defend possible claims.

You may exercise your data protection rights by contacting the following email address: protecciondedatos@rovi.es

If your rights have been infringed, particularly if you have not received satisfaction when exercising them, you may file a complaint with the supervisory authority.

How can I manage cookies?

You may allow, block or delete the cookies installed on your device using the “COOKIE OPTIONS” button that appears when entering this Website and also through your browser settings. You can find information on how to do this for the most common browsers on the following links:
• Explorer: https://support.microsoft.com/es-es/help/17442/windows-internet-explorer-delete-manage-cookies
• Firefox: https://support.mozilla.org/es/kb/habilitar-y-deshabilitar-cookies-sitios-web-rastrear-preferencias
• Chrome: http://support.google.com/chrome/bin/answer.py?hl=es&answer=95647
• Safari: https://support.apple.com/es-es/guide/safari/sfri11471/mac

To prevent Google Analytics from tracking you on all websites, please visit http://tools.google.com/dlpage/gaoptout.

We inform you, however, of the possibility that disabling cookies may prevent or hinder browsing and/or the provision of the services offered on this Website.

Updates and changes to the Cookie Policy

The Company may make changes to this Cookie Policy to adapt it to current legal or regulatory requirements and/or any instructions issued by the Agencia Española de Protección de Datos (Spanish Data Protection Agency). Therefore users are recommended to visit this Website from time to time to keep updated on any changes that may have been made.

If you would like further information on the use of cookies, you may request it from us at the following email address: protecciondedatos@rovi.es

Additional data protection information

For further information on any personal data processing that may be carried out, please see our Privacy Policy .

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EXERCISE OF RIGHTS GDPR

A) FORM FOR EXERCISE OF RIGHT OF ACCESS

ROVI GROUP, in compliance with the obligations set out in the personal data protection legislation, acknowledges and guarantees to the persons whose personal data form part of its files, with the legal limitations, the rights of access, rectification, erasure, restriction of processing, portability and objection.

This request should be sent to GRUPO ROVI: C/ Julián Camarillo 35, 28035 Madrid, or to the e-mail address protecciondedatos@rovi.es.

Particulars of applicant:

Mr/Ms ...................................................................................., of legal age, domiciled at ..................(Street name).......................................... ..(Number).., …………..(Municipality)............., ....(Province)...., …(Postcode)…, with national identity document No. ..........................., hereby expresses his/her wish to exercise his/her right of access, in accordance with the provisions of article 15 of the European General Data Protection Regulation.

He/she requests:

1.- That he/she be provided, free of charge, with information on the personal data processed that concern him/her [specify the personal data to which access is requested].
2.- That the information requested should be sent by e-mail to the address stated above.

Signature of applicant:

………...(Place)..............., ...........(Date)............, 20..

B) FORM FOR EXERCISE OF RIGHT TO RECTIFICATION

ROVI GROUP, in compliance with the obligations set out in the personal data protection legislation, acknowledges and guarantees to the persons whose personal data form part of its files, with the legal limitations, the rights of access, rectification, erasure, restriction of processing, portability and objection.

This request should be sent to GRUPO ROVI: C/ Julián Camarillo 35, 28035 Madrid, or to the e-mail address protecciondedatos@rovi.es.

Particulars of applicant:

Mr/Ms ...................................................................................., of legal age, domiciled at ..................(Street name).......................................... ..(Number).., …………..(Municipality)............., ....(Province)...., …(Postcode)…, with national identity document No. ..........................., hereby expresses his/her wish to exercise his/her right to rectification, in accordance with the provisions of article 15 of the European General Data Protection Regulation.

He/she requests:

That the personal data set out below be rectified and replaced by those mentioned for each item:
……………………………………..
……………………………………..
……………………………………..
……………………………………..
Signature of applicant:

………...(Place)..............., ...........(Date)............, 20..

C) FORM FOR EXERCISE OF THE RIGHT TO ERASURE

ROVI GROUP, in compliance with the obligations set out in the personal data protection legislation, acknowledges and guarantees to the persons whose personal data form part of its files, with the legal limitations, the rights of access, rectification, erasure, restriction of processing, portability and objection.

This request should be sent to GRUPO ROVI: C/ Julián Camarillo 35, 28035 Madrid, or to the e-mail address protecciondedatos@rovi.es.

Particulars of applicant:

Mr/Ms ...................................................................................., of legal age, domiciled at ..................(Street name).......................................... ..(Number).., …………..(Municipality)............., ....(Province)...., …(Postcode)…, with national identity document No. ..........................., hereby expresses his/her wish to exercise his/her right to erasure, in accordance with the provisions of article 15 of the European General Data Protection Regulation.

He/she requests:

That the following personal data concerning me be erased:
.................................................................................................................................

Reasons for erasure:

The reasons for which erasure of the data is requested are as follows: ...................................................................................................................................................................................................................................................................................................................................................................................................

Signature of applicant:

………...(Place)..............., ...........(Date)............, 20..

D) FORM FOR EXERCISE OF THE RIGHT TO RESTRICTION OF PROCESSING

ROVI GROUP, in compliance with the obligations set out in the personal data protection legislation, acknowledges and guarantees to the persons whose personal data form part of its files, with the legal limitations, the rights of access, rectification, erasure, restriction of processing, portability and objection.

This request should be sent to GRUPO ROVI: C/ Julián Camarillo 35, 28035 Madrid, or to the e-mail address protecciondedatos@rovi.es.

Particulars of applicant:

Mr/Ms ...................................................................................., of legal age, domiciled at ..................(Street name).......................................... ..(Number).., …………..(Municipality)............., ....(Province)...., …(Postcode)…, with national identity document No. ..........................., hereby expresses his/her wish to exercise his/her right to restriction of processing, in accordance with the provisions of article 15 of the European General Data Protection Regulation.

He/she requests:

That the processing of the following personal data be restricted: .................................................................................................................................
Signature of applicant:

………...(Place)..............., ...........(Date)............, 20..

E) FORM FOR EXERCISE OF THE RIGHT TO DATA PORTABILITY

ROVI GROUP, in compliance with the obligations set out in the personal data protection legislation, acknowledges and guarantees to the persons whose personal data form part of its files, with the legal limitations, the rights of access, rectification, erasure, restriction of processing, portability and objection.

This request should be sent to GRUPO ROVI: C/ Julián Camarillo 35, 28035 Madrid, or to the e-mail address protecciondedatos@rovi.es.

Particulars of applicant:

Mr/Ms ...................................................................................., of legal age, domiciled at ..................(Street name).......................................... ..(Number).., …………..(Municipality)............., ....(Province)...., …(Postcode)…, with national identity document No. ..........................., hereby expresses his/her wish to exercise his/her right to data portability, in accordance with the provisions of article 15 of the European General Data Protection Regulation.

He/she requests:

• That the personal data provided to the data controller be sent to me in a structured, commonly used and machine-readable format.
• That the personal data provided to the data controller be sent to the following company _______________________ in a structured, commonly used and machine-readable format.
[LEAVE THE APPLICABLE OPTION AND DELETE THE OTHER]

Signature of applicant:

………...(Place)..............., ...........(Date)............, 20..

F) FORM FOR EXERCISE OF THE RIGHT TO OBJECT

ROVI GROUP, in compliance with the obligations set out in the personal data protection legislation, acknowledges and guarantees to the persons whose personal data form part of its files, with the legal limitations, the rights of access, rectification, erasure, restriction of processing, portability and objection.

This request should be sent to GRUPO ROVI: C/ Julián Camarillo 35, 28035 Madrid, or to the e-mail address protecciondedatos@rovi.es.

Particulars of applicant:

Mr/Ms ...................................................................................., of legal age, domiciled at ..................(Street name).......................................... ..(Number).., …………..(Municipality)............., ....(Province)...., …(Postcode)…, with national identity document No. ..........................., hereby expresses his/her wish to exercise his/her right to object to processing of the data, in accordance with the provisions of article 15 of the European General Data Protection Regulation.

He/she requests:

That, with the limitations provided for by law, my personal data should no longer be used for the following purposes:.................................................................................................................................
Signature of applicant:

………...(Place)..............., ...........(Date)............, 20..