S.C.

________________________
Nr______Data ________________

CERERE

Subsemnat (ul/a)___________________________________ domiciliat in ___________________

Str. _____________________________nr. _____, bloc____, scara_____, etaj____, ap.____, judet/sector
____________,

telefon________________,

act

identitate

______,

seria____,

nr_____________,

CNP _________________________ eliberat de _______________ la data_______________ in calitate

de

reprezentant legal al SC ______________________________ avand numar de ordine in registrul comertului

__________________, cod unic de inregistrare ______________ cu sediul

social in localitatea

______________________str.____________________ nr. _____, bloc____, scara_____, etaj____, ap._____,

judet/sector

____________

cod

postal

________________

telefon_________________,fax________________, e-mail________________,
autorizatia

sanitara

veterinara

pentru

mijlocul

de

transport

casuta

postala____________

va rog sa binevoiti a elibera

____________________________

seria_________________, capacitatea____________, nr. de nmatriculare (auto, avion, nava, vagon)

_____________________________________________________________________________________,
proprietatea__________________________________adresa

___________________________________

_____________________________________________________________________________________

I. Condiii de temperatur:
1. fr regim termic
3. T de congelare
2. T de refrigerare
4. alt regim termic

II. Condiii de transport:

1.agatat
3. ambalat
2. vrac
4. impachetat

Capacitatea de transport __________________________________________________

Achitat cu chitanta nr.______________

Data _____________

Semnatura si stampila ______________________

Rezultatul verificarii mijlocului de transport, in conformitate cu prevederile legislatiei in vigoare*:

*Se va completa de catre personalul sanitar veterinar de specialitate care efectueaza verificarea