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Model -

CTRE
INSPECTORATUL GENERAL AL POLIIEI ROMNE
DIRECIA DE ORDINE PUBLIC
Subsemnatul(a)____________________________________________________, domiciliat()
n
____________________________________________________________________________
posesor al 1 ____________________ seria ________, nr.___________________, eliberat de
__________________________________
la
data
de
____________,
______________________________, telefon _______________, fax ______________, email
________________________, web _______________________________, v transmit documentele
necesare nscrierii n Registrul Naional al Evaluatorilor de Risc la Securitate Fizic.
Activitile de evaluare a riscurilor de securitate fizic se vor derula pentru angajatorul 2
_________________________________________________________________________, cu sediul
social_______________________________________________ i administrativ__________________
_______________________________________, nmatriculat la O.R.C. cu numrul de ordine
__________________________ i codul unic _________________, avnd ca activiti codurile
CAEN 3 7022 / 7112 / 7490, e-mail __________________________________________________,
tel./fax ________________________________.
Competenele profesionale de evaluator au fost dobndite prin absolvirea cursului organizat de
formatorul_______________________________________________________________________, n
perioada_____________________, autorizat sub nr._____________________, desfurat n
localitatea ____________________________________, cu susinerea examenului de absolvire n data
de _____________, n prezena comisiei formate din: ____________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
___________________________________________.
Anexez, urmtoarele documente 4:
act de identitate ____________________ seria _______ nr._______________________
certificat de absolvire seria _________ nr. _____________ eliberat la data _______________
certificat de cazier judiciar nr. _______________ din _________________
certificat de nregistrare la ORC seria ________ nr. ___________________
certificat constatator emis de ORC nr. ________________ din ____________________
documente de atestare calitate angajat _________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Declar pe propria rspundere c datele menionate corespund realitii.
Data _____________

Semntura ___________

tip act de identitate (CI/paaport/permis edere)

numele i datele de identificare ale angajatorului
3
se taie opiunile care nu corespund
4
documentele prevzute de art. 2 din Dispoziia I.G.P.R. nr. 73/2013
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