CERERE

ELIBERARE EXTRAS DE CONT

Numele i prenumele solicitantului _______________________________________________

Cod numeric personal _________________________________________________________
B.I. / C.I. _____ Seria _____ Nr. ___________________
Domiciliu ___________________________________________________________________
___________________________________________________________________

Prin prezenta solicit Registrului Mioria eliberarea unui extras de cont.

Data _________________ Dat n faa mea,

Semntura Nume i prenume ______________________

solicitantului Calitatea _____________________________
___________________________ Semntura ___________________________

Am primit, n original, astzi _____________ extrasul de cont solicitat,

Nume i prenume ______________________

Semntura ___________________________