CERTIFICAT DE DESFSURARE A ACTIVITII

REGULAMENTUL (CE) NR. 561/2006 SAU ACORDUL A.E.T.R.

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ATTESTATION OF ACTIVITIES UNDER REGULATION (EC) NO 561/2006

OR
THE EUROPEAN AGREEMENT CONCERNING THE WORK OF CREWS OF VEHICLES ENGAGED IN INTERNATIONAL ROAD
TRANSPORT (AETR) (1)
A se completa prin dactilografiere i a se semna nainte de cltorie.
A se pstra impreun cu inregistrarea original a aparaturii de control, n cazul n care este necesar pstrarea nregistrrii
Falsificarea certificatelor constituie infractiune.
To be filled in by typing and signed before a journey.To be kept with the original tachograph records wherever they are required to be kept
False attestations constitute an infringement

SC CONSORTIS SV SRL

1. Numele intreprinderii:
(Name of the undertaking)
2. Strada, codul potal, oraul, ara:

bul.Dacia, 22-118, 2060, mun. Chisinau,

R.Moldova
(Street address, Postal code, City, Country)
3. Numrul de telefon (inclusiv prefixul internaional):
(Telephone number (including international prefix)
4. Numrul de fax (inclusiv prefixul internaional):
(Fax number (including international prefix)
5. Adresa de e-mail:
(E-mail address)

0037322 725403
0037322 725403
consortis@mail.ru

Subsemnatul, (subsemnata) (I, the undersigned),

SEVCENCO Victor

6. Numele i prenumele:
(Name)
7. Funcia ocupata in intreprindere:
(Position in the undertaking)

Director

declar c conductorul auto (declare that the driver)

8. Numele i prenumele:
Agrici Vitalie
(Name)
9. Data naterii:
17.06.1974
(Date of birth)
10. Numrul permisului de conducere, sau a crii de identitate sau a paaportului:
(Driving licence number or Identity card number or Passport number)
11. Care lucreaza n cadrul ntreprinderii de la (ziua/luna/anul) from (day-month-year)
03.02.2014
pentru perioada, (for the period )
12. de la:
ora:
08:00
ziua:
From:
(time)
(day)
13. la:
ora:
07:15
ziua:
To:
(time)
(day)

15.
16.
17.
14.

31

luna:

(month)

02

luna:

(month)

octombrie
(year)
noiembrie
(year)

1444000010

anul:

2015

anul:

2015

s-a aflat n concediu medical (was on sick leave) (*)

s-a aflat n concediu de odihn (as on annual leave) (*)
s-a aflat n concediu sau n repaus (was on leave or rest) (*)

a condus un vehicul exceptat de la aplicarea Regulamentului (CE) nr.561/2006 sau AE.T.R.

Drove a vehicle exempted from the scope of Regulation (EC) No 561/2006 or AETR (*)

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18. desfsura o alt activitate, dect condusul (performed other work than driving)
19. era disponibil (was available)
20. Pentru intreprindere, localitatea
For the undertaking, place

Chisinau

data:

02.11.2015

Semntura ______________________
Signature
21. Subsemnatul, conductor auto, confirm c nu am condus un vehicul care intr n domeniul de aplicare al
prevederilor
Regulamentului (CE) nr. 561/2006 sau AETR . (I, the driver, confirm that I have not been driving a vehicle falling under
the scope of Regulation (EC) No. 561/2006 or AETR during the period mentioned above.)
22. Localitatea
Place

s. Danceni

data:

02.11.2015

Semntura conductorului auto ______________________

Signature of the driver
Acest formular poate fi obinut n versiune electronic i imprimabil pe site-ul http://arr.ro/verticala/Formular
%20atestare.doc
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This form is available in an electronic and printable version on the Internet at ec.europa.eu.

Se alege doar una dintre csuele

(*) Only one of the boxes.
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