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UNITATEA SANITARĂ ...............................................

Nr. Convenție privind eliberarea CCM ........................

DECLARAȚIE

Subsemnatul .....................................reprezentant legal al unității sanitare

.................................cu următoarele date de identificare: cod fiscal ...................
localitatea ........................................... strada ..........................nr. ............................
județul ........................., declar pe propria răspundere că, în luna .....................................
anul................... nu am eliberat certificat de concediu medical.

Reprezentant legal al unității sanitare

.......................................................

Data ......................................

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