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Karta Zgloszeniowa

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4 views4 pages

Karta Zgloszeniowa

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chrymchrym

karata zglaoszeniowa

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KAR TA

Z G O SZ E N IA

do________ Izby Lekarsko-Weterynaryjnej w

Numer lekarza weterynarii

Wpis do rejestru Izby Lekarsko-Weterynaryjnej

_____________________

______________________ ________________

nadaje Izba Weterynaryjna

dzie

m-c

rok

numer uchway

1. Nazwisko _________________________________________________________________________
2. Nazwisko rodowe ______________________________________________________
3. Imiona _______________________________________________________________
4. Nr ew. pesel __________________________ NIP ____________________________
5. Imiona rodzicw _______________________________________________________
6. Data i miejsce urodzenia _________________________________________________
7. Narodowo ______________________________ Obywatelstwo ________________
8. Nazwa uczelni _________________________________________________________
9. Nr i data wydania dyplomu ___________________ stopie naukowy ____________
10. Specjalizacja __________________________________________________________
11. Adres zameldowania____________________________________________________

12. Adres korespondencyjny _________________________________________________

13. Telefon kontaktowy _adres e mail ____

14. Przebieg pracy zawodowej:

Okres .od. do

Zakad pracy

Adres

funkcja

15. Dziaalno w samorzdzie Lekarsko -Weterynaryjnym :

biega : ______________________________________________________________
dobra : _______________________________________________________________
saba : _______________________________________________________________
17. Uwagi :

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

_________________________________
miejscowo

___________________
data

_____________________
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