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Inspectoratul Teritorial de Muncă Cluj

Subsemnatul(a)__________________________________născut(ă) la data de __________________

CNP_________________________________domiciliat(ă) în loc__________________________________
str.__________________________________, nr._____,bl._____, sc._____,ap.___, jud.________________
tel__________________, am lucrat în perioada ______________--______________ în functia de ________
____________________la angajatorul (firma) _____________________________________, cu sediul în
loc. _______________________________________, str.______________________________, nr._____,
bl._____, sc._____, ap.______,jud.________________, tel._____________________________, cu punct
de lucru în localitatea ________________________________, str.______________________________,
nr._____, bl._____, sc._____, ap.______,jud.________________, tel____________________________,
reprezentată prin (nume şi prenume patron) ___________________________________, domiciliat în
loc.______________________ str.______________________________, nr._____, bl._____, sc._____,
ap.______,jud.________________tel._________________________.
În cele ce urmează vă relatez următoarele:_______________________________________________
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** Notă: Se va anexa copia actului de identitate
Cluj-Napoca Semnătura
Data ____________