Part to be filled in by the undertaking

1)

Name of the undertaking: .FORUM

TIR SRL

2)

Street address, postal code, city, country: REPUBLICA

3)

Telephone number (including international prefix):

4)

Fax number (including international prefix):+37322226673

MOLDOVA CHISINAU

+37322220098

5)
E-mail address: nicoltrans@gmail com
the undersigned:

TIRON ARTIOM

6)

Name and first name

7)

Position in the undertaking:DIRECTOR

eclare that the driver:8)

Name and first name:

CABAC VALERIU

9)

Date of birth (day/month/year)

10)

Driving licence or identity card or passport number:

11)

who has started to work at the undertaking on (day/month/year):

005411774
21 09 2000

or the period:

12)

from (hour/day/month/yea 18 :00

13)

to (hour/day/month/year )

14)

was on sick leave***

/ 17/07/2013

22:00 /17/08/2013

(15) was on annual leave***

16) X

was on leave or rest***

17)

drove a vehicle exempted from the scope of Regulation (EC) 561/2006 or the AETR ***

18)

performed other work than driving***

19)

was available***

20)

Place CHISINAU Date17/08/.2013

Signature:

21
EGULATION (EC) 561/2006 OR THE AETR)
To be filled in by typing and signed before a journey. To be kept with the original control device record ATTESTATION
(Rs wherever they are required to be kept
FALSE ATTESTATIONS CON

OF ACTIVITIES

STITUTE AN INFRINGEMENT

()

I, the driver, confirm that I have not been driving a vehicle falling under the scope of Regulation (EC) 561/2006 or the AETR during the period

mentioned above.
( 22)Place

CHISINAU Date17/08/.2013

Signature of the driver: