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SESIZARE

Subsemnatul(a) ________________________________________________, domiciliat() n localitatea


_________________________________ str. ________________________________________,
nr . _________, bl. ________, sc. ______, ap. ______, telefon ________________________________,
posesor al buletinului (cartii) de identitate seria____ nr. _____________,
DECLAR urmatoarele:
In perioada de la (luna, anul) _________________________ pana la _____________________ , am lucrat
la ________________________________________________________________, cu sediul in (localitatea)
____________________________________,
str.
________________________________________,
nr._______, punct de lucru _____________________________________________________________,
telefon
_____________________________________,
administrator
(director,
patron)
__________________________________.
In aceasta perioada

- AM AVUT
- NU AM AVUT
ncheiat contract individual
________________________________________

de

munca

cu

S.C.

Si
-

AM SEMNAT
NU AM SEMNAT state de plat la acest angajator

Mai precizez urmatoarele:


_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

DATA:

SEMNATURA:

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