Anexa nr. 5 la Hotrrea 2 / 4 din 2 decembrie 2011 a Comisiei speciale de desfurare a alegerilor pentru funcia de Preedinte al Republicii Moldova Model

CERTIFICAT DE SNTATENumele, prenumele___________________________________________________ Data naterii ________________________________________________________ Locul de munc, funcia_______________________________________________ Concluzii privind starea sntii: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ (Anexa - pentru dosar) Medicii, membri ai Comisiei: Numele, prenumele Profilul medical Semntura

Preedintele Comisiei medicale:(numele, prenumele, semntura)

Chiinu, _____________________20111

Anex la Certificatul de sntate DATELE examenului medical Internist___________________________________________________________ __________________________________________________________________ __________________________________________________________________ Chirurg____________________________________________________________ __________________________________________________________________ __________________________________________________________________ neurolog___________________________________________________________ __________________________________________________________________ __________________________________________________________________ psihiatru___________________________________________________________ __________________________________________________________________ __________________________________________________________________ narcolog __________________________________________________________ __________________________________________________________________ __________________________________________________________________ oftalmolog _________________________________________________________ __________________________________________________________________ __________________________________________________________________ otorinolaringolog ____________________________________________________ __________________________________________________________________ __________________________________________________________________

Semntura preedintelui Comisiei medicale L..2