ANEXA 2

Anex la pct. 7
F-02-PG-01

DIRECTIA PUBLICA DE PROTECTIE SOCIALA

CENTRUL MAGNOLIA
FI INDIVIDUAL A VRSTNICULUI
1. DATE PERSONALE
NUME__________________________PRENUME__________________________________
NSCUT LA DATA DE __________________N __________________________________
POSESOR AL ______SERIA_________NR_________________ELIBERAT DE POLIIA
__________________LA DATA DE________________CU DOMICILIUL N TRGU JIU,
Str._____________________, Bl.__________, Sc.__________, Etj._________, Ap.________,
Nr.____________. TELEFON: _______________________________________
2. STARE CIVIL

o CSTORIT CU _________________________________________ N
VRST DE __________.

o CONCUBINAJ CU ____________________________________________
o NECSTORIT
o DIVORAT
o VDUV
o ARE_______COPII
o NU ARE COPII
ESTE INSCRIS LA ALTE CENTRE/CLUBURI FINANTATE DE LA BUGETUL LOCAL/DE
STAT/FONDURI EUROPENE
DA ____ NU ____
MODUL DE FRECVENTARE A CLUBULUI

o ZILNIC_________ORE
o LA 2-3 ZILE_____ORE
o 1 ZI PE SAPTMN____ORE
3. STAREA SANTII

o BUN

o SUFER DE __________________________________________________
CONFORM ACTULUI MEDICAL ________________________________
NUME, PRENUME: ____________________________________________
SEMNATURA: ________________________________________________
DATA: _______________________________________________________