Subsemnatul/a ________________________________________________________

domiciliat/a in: _______________________________________________________ _________

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salariat/a al/a S.C. ................. S.R.L. cu Sediul Social in .................
sector ......, ...................................
DECLAR ca:

traseul de deplasare la serviciu si retur este urmatorul:

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mijlocul/mijlocele de deplasare este/ sunt:

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durata
de
deplasare
este
de
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Semnatura _________________________
Data ___.___.______