Periodical title:

Frequency or publication dates:

Composition of the Management Committee:

Name and registered office of the company or association publishing or publishing the periodical:

Legal form of the company:

Form and date of the instrument of incorporation and the statutes, of which a copy shall be annexed:

Functions performed in the company by members of the Management Committee:

Full marital status, profession and address of the Director, members of the Management Committee, members of the Management Board and managers:

Name and address of the Publisher:

Business name and address of the printing works:

Name and address of distributor:

The declaration must expressly state the following: (repeat 7 points)

The undersigned expressly declare that they fulfill the conditions laid down in Article 4 of the Law of 16 July 1949, namely:

1. Be a French national or a national of a country of the European Economic Area (EEA)
2. Enjoying civil rights
3. Not to have been subject to disciplinary action leading to exclusion from a post in education or in a public or private educational or re-education establishment
4. Not having been deprived of all or part of the rights of parental authority,
5. Not to have been convicted of collaboration or an offense contrary to morality, of any crime or of abandonment of family, of the offenses provided for in articles 223-3, 223-4, 224-4, 227-1, 227-2, 227-5 to 227-10, 227-12 and 227-13 of the Criminal Code), or of theft, breach of trust, fraud or offense punishable by law by penalties of fraud fraud for embezzlement committed by a public depositary, extortion of funds or assets, or for concealment of things obtained by means of these offenses, or for defamation when, in the latter case, the sentence imposed will have included a prison sentence or for acts provided for in Articles L.1343-4,L 3421-1,L 3421-2,L 3421-4, L 5132-8 and L 5432-1 of the Public Health Code;
6. have not been members of the management or management committee of a periodical publication referred to in Article 1 and suspended for a period exceeding 2 months,
7. Not having been previously convicted of one of the offenses provided for by the Law of 16 July 1949.