Subsemnatul/a ___________________________________________________, cu
domiciliul in _________________ str. ____________________________________
nr. __, bl.__, sc.__, et.__, ap.__, sector/judet ___________________,
legitimat cu CI seria ___, nr. ________, eliberat de __________ la data de
___________, CNP: ____________________________, in calitate de student
aflat
in
practica
in
cadrul
Programului
prin
prezenta
Data:____________________
Voluntar :__________________________
________
Semnatura :_______________________
_________