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S.P.C.R.P.C.I.V.

-IASI

DOMNULE COMANDANT

Subsemnatul(a)______________________________fiul(fiica)lui_____________
____________ si al __________________________nascut la data
de________________in _______________________judetul __________________cu
domiciliul stabil in____________________________________________
str.__________________________________nr.______bl._________sc._________et.___
____ap._______ in calitate de _________________________aduc la cunostinta
urmatoarele:

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Declar prin prezenta pe propria raspundere si sub sanctiunea Codului Penal ca


cele relatate de mine mai sus corespund cu realitatea.

DATA SEMNATURA