2012 Anexa 1 - Cerere de Internare_varstnici

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  • Anexa 1 JUDEUL HUNEDOARA PRIMRIA .. NR.. din ..

    Cerere internare

    Subsemnatul (a)_________________________________

    ________________ domiciliat (a) ______________________,

    str.______________________ nr. ____, bl. _______, ap. ____

    telefon _____________, posesor BI / CI / CP seria _____ nr.

    ________________ solicit internarea d-nei / d-lui_________

    ______________________________________, grad de

    rudenie __________ domiciliat (a) n ___________________ str. _______________________, nr. _____, bl. ______, ap.

    ______, telefon _____________, posesor BI / CI / CP seria

    _____ nr. ______________, persoana vrstnic (da / nu) n centrul ______________________ aflat n coordonarea Direciei Generale de Asisten Social i Protecia Copilului Hunedoara, deoarece:

    _____________________________________________________________________________________

    _____________________________________________________________________________________

    _____________________________________________________________________________________

    _____________________________________________________________________________________

    _____________________________________________________________________________________

    Data Semntura solicitant

    ___________________ ________________________________