Îáðàçåö çàÿâëåíèÿ
äëÿ
îñóùåñòâëåíèÿ àäìèíèñòðàòèâíîé ïðîöåäóðû
Íà áëàíêå ôèðìû
Èñõ. ¹ _____ äàòà «____» ______
202 ã.
ÃÓ «ÄÎÊØÈÖÊÈÉ ÐÀÉÎÍÍÛÉ ÖÅÍÒÐ ÃÈÃÈÅÍÛ È ÝÏÈÄÅÌÈÎËÎÃÈÈ»
Îò
Ô.È.Î.,
íàèìåíîâàíèå ïðåäïðèÿòèÿ, òèï
àäðåñ
ÓÍÏ ___ ___
___ ___ ___
___ ___ ___
___
___________________________________________________________________________
íàèìåíîâàíèå
ãîñóäàðñòâåííîãî îðãàíà, èíîé ãîñóäàðñòâåííîé îðãàíèçàöèè, îñóùåñòâèâøèõ
ãîñóäàðñòâåííóþ ðåãèñòðàöèþ
Êîíòàêòíûé òåëåôîí:
__ __ __ __ __ __ __
ÇÀßÂËÅÍÈÅ
Ïðîñèì (ïðîøó) îñóùåñòâèòü àäìèíèñòðàòèâíóþ ïðîöåäóðó: _____________________________________________________________________________
(íàèìåíîâàíèå àäìèíèñòðàòèâíîé ïðîöåäóðû)
_____________________________________________________________________________
(óêàçàòü íàèìåíîâàíèå ðàáîò, óñëóã, îáúåêò)
____________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Ïðåäîñòàâëåíû äîêóìåíòû è (èëè) ñâåäåíèÿ äëÿ îñóùåñòâëåíèÿ
àäìèíèñòðàòèâíîé ïðîöåäóðû:
1.____________________________________________________________________________
2____________________________________________________________________________3.____________________________________________________________________________
Ïðåäñòàâëåíî äîêóìåíòîâ è (èëè) ñâåäåíèé íà ëèñòàõ â _______ ýêç.
Îïëàòó ãàðàíòèðóåì.
(íàèìåíîâàíèå äîëæíîñòè) (ïîäïèñü) (èíèöèàëû, ôàìèëèÿ)
Ì.Ï.
(äàòà)