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Operator de date cu caracter personal

notificat cu nr. 5285 / 5286 / 5287

1UvQUHJLVWUDUH Data:
___.___.______

Cod de cerere SIMISC:

CERERE
de prestare a unui serviciu consular

1. DATELE DE IDENTIFICARE ALE SOLICITANTULUI

1.1. Numele de Numele de familie actual: Numele de familie la QDWHUH: Alte nume de familie anterioare:
familie:

1.2. Prenumele: Prenumele actual: 3UHQXPHOHODQDWHUH: Alte prenume anterioare:

&HWHQLD 1.4. Codul numeric personal:

1.5. Sexul:
Localitatea:
'DWDQDWHULL /RFXOQDWHULL
-XGHXO6HFWRUXO
Ziua Luna Anul
DUD
3DDSRUWVLPSOX 3DDSRUWVLPSOX 3DDSRUWVLPSOX 7LWOXGHFOWRULH
electronic temporar
Carte de identitate Buletin de Carte de identitate 3DDSRUWGLSORPDWLF
'RFXPHQWXOGH identitate provizorie
identitate 3DDSRUWGHVHUYLFLXHOHFWURQLF Alt document:
$XWRULWDWHDHPLWHQW 'DWDHOLEHUULL 'DWDH[SLUULL

Ziua Luna Anul Ziua Luna Anul


DUD Localitatea: -XGHXO6HFWRUXO5HJLXQHD
1.9.Domiciliul legal:
(conform documentelor Strada: Nr.: Bloc: Apartament: &RGSRWDO
GHLGHQWLWDWHURPkQHWL

5HHGLQD DUD Localitatea: -XGHXO6HFWRUXO5HJLXQHD


DFWXDO

GDFGLIHUGH Strada: Nr.: Bloc: Apartament: &RGSRWDO


adresa de domiciliu)

1XPUGH $GUHVGHHPDLO
telefon:

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2. SERVICIUL CONSULAR SOLICITAT
2.1. Obiectul
cererii:
2.2. Tipul
1XPUXOGHGXSOLFDWHGRULW
documentului:

3.3527(&,$'$7(/25&8&$5$&7(53(5621$/

3.,QIRUPDUHSULYLQGUHJLPXOSURWHFLHLGDWHORUFXFDUDFWHUSHUVRQDOFROHFWDWHSULQSUH]HQWDFHUHUH

'DWHOHSHUVRQDOHIXUQL]DWHVXQWSUHOXFUDWHGH0LQLVWHUXO$IDFHULORU([WHUQHLQFOXVLYGHPLVLXQLOHGLSORPDWLFHLRILFLLOHFRQVXODUHDOH
5RPkQLHLGLQVWULQWDWHSULQH[HUFLWDUHDSUHURJDWLYHORUGHDXWRULWDWHSXEOLFvQVWULFWFRQIRUPLWDWHFXSUHYHGHULOH/HJLLQU9
SXWHLH[HUFLWDGUHSWXULOHGHDFFHVGHLQWHUYHQLHLGHRSR]LLHFXSULYLUHODSUHOXFUDUHDGDWHORUFXFDUDFWHUSHUVRQDOvQFRQGLLLOHSUHY]XWHGH
/HJHDQUSULQWURFHUHUHVFULVGDWDWLVHPQDWDGUHVDWPLVLXQLLGLSORPDWLFHVDXRILFLXOXLFRQVXODUFDUHSUHLDLSURFHVHD]
SUH]HQWDVROLFLWDUHVDX0LQLVWHUXOXL$IDFHULORU([WHUQHDO5RPkQLHL

3.'HFODUDLDVROLFLWDQWXOXLSULYLQGGDWHOHFXFDUDFWHUSHUVRQDOIXUQL]DWHSULQSUH]HQWDFHUHUH

$POXDWODFXQRWLQXUPWRDUHOHWRDWHGDWHOHPHOHSHUVRQDOHvQVFULVHvQSUH]HQWXOIRUPXODUYRUILSXVHODGLVSR]LLDDXWRULWLORUURPkQH
FRPSHWHQWHLSURFHVDWHGHFWUHDFHVWHDGXSFD]vQVFRSXOOXULLXQHLGHFL]LLFXSULYLUHODVROLFLWDUHDGHID$FHVWHGDWHSRWILLQWURGXVHL
VWRFDWHvQED]HOHGHGDWHDFFHVLELOHDXWRULWLORUURPkQHFRPSHWHQWH8UPDUHVROLFLWULLPHOHH[SUHVHDXWRULWLOHFRQVXODUHFRPSHWHQWHSHQWUX
SURFHVDUHDSUH]HQWHLVROLFLWULPYRULQIRUPDFXSULYLUHODPRGDOLWDWHDvQFDUHvPLSRWH[HUFLWDGUHSWXOGHDYHULILFDGDWHOHSHUVRQDOHIXUQL]DWH
GHDGLVSXQHPRGLILFDUHDVDXvQGHSUWDUHDORUGDFVHGRYHGHVFLQFRUHFWHvQFRQIRUPLWDWHFXSUHYHGHULOHOHJLVODLHLvQYLJRDUHvQ5RPkQLD
'HFODUFGXSWLLQDPHDWRDWHGDWHOHIXUQL]DWHVXQWFRUHFWHLFRPSOHWH'HFODUFDPFXQRWLQGHIDSWXOFRULFHGDWHIDOVHIXUQL]DWH
FRQGXFODUHVSLQJHUHDSUH]HQWHLVROLFLWULVDXODDQXODUHDGRFXPHQWHORUHPLVHvQED]DDFHVWHLDLSRWGXFHODGHFODQDUHDXUPULULLPHOHSHQDOH
vQFRQIRUPLWDWHFXOHJHDURPkQ

4.'$7$,/2&8/&203/(75,,6(01785$

4.'DWDFRPSOHWULLFHUHULL

Ziua Luna Anul

4./RFXOFRPSOHWULLFHUHULL 0LVLXQHDGLSORPDWLF2ILFLXO Localitatea: DUD


consular:

4.6HPQWXUDVROLFLWDQWXOXL

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