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 ________________ casuta postala____________
telefon_________________,fax________________, e-mail________________,

va rog sa binevoiti a

elibera autorizatia sanitara veterinara pentru mijlocul de transport ____________________________

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
DSVSA-FR-CASVA_Ed2

DSVSA-FR-CASVA_Ed2