MODEL 12

DATA
ADMIS(ctg)..
Examinator
Semnatura.

FISA DETINATORULUI PERMISULUI DE CONDUCERE

NUMARUL PERMISULUI DE
Numele________________________________________ CONDUCERE / DATA ELIBERARII
Prenumele______________________________________
Prenumele Tata ______________________________ ________________________________________
parintilor Mama ____________________________ (se completeaza de S.P.C.R.P.C.I.V.)

Categoria
Data
obtinerii
Sex M (masc), F (fem) ______ Nume anterior____________________________ ____________________________
Data nasterii: (an, luna, zi) ______________________________________________ ____________________________
Locul nasterii: judetul (sectorul)______________ localitate____________________ _____________________________
tara ___________________________________________________ _____________________________
Domiciliul: judet (sector)____________ localitate ___________________________ _____________________________
str. _________________________________________________________ _____________________________
bloc ___________________ scara ___________apart._________________ _____________________________
Cod numeric personal _________________________________________________ _____________________________
Act identitate: (felul, serie, numarul) ______________________________________ _____________________________
Cetatenie ___________________________________________________________ Numarul permisului anterior /
Profesia _________________________ ocupatia ___________________________ data emiterii
Locul de munca: organ tutelar, minister etc. ________________________________ _____________________________
unitate _____________________________________________________
Telefon acasa ___________________ Telefon serviciu ___________________

Mentiuni: Poarta ochelari de corectie

Restrictii medicale adaptat infirmitatii cu ambreiaj automatic

Tractor Tramvai Troleibuz

Tipul operatiunii: Eliberare prima categorie

Adaugare categorie
Preschimbare
Modificare Adresa Nume
Duplicat Pierdere furt
Deteriorare

Semnatura solicitant

Data ________________________

Gradul, Numele si prenumele lucratorului

care a completat fisa ____________________________________________________________________
Semnatura lucrator ______________________________________

Rubricile din chenarul ingrosat se completeaza de mana cu majuscule de catre solicitant