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SCAFCGSMREALPITESTISRL

(Denumireaangajatorului)
____________RO30451584___________
(CodfiscalC.U.I./C.N.P.angajator/persoanfizic)

_______________________________________
(Adresaangajator)

_______________________________________
(Nr.denregistrare/data)

ADEVERIN
Prinprezentasecertificfaptulcdomnul/doamna_______________________
_________________________________,C.N.P.__/__/__/__/__/__/__/__/__/__/__/__/__/,actde
identitate B.I. / C.I., seria _____, nr.______________, eliberat
de____________________________
__________________________________,ladatade_____________________,cudomiciliul n
localitatea_________________________________,str.___________________________________
nr.________,bl._______________,sc.______,ap.______,sectorul/judeul__________________,
arecalitateadesalariatiisareinutiviratlunarcontribuiapentruasigurrilesocialedesntate,
potrivitLegiinr. 95/2006privindreforma ndomeniulsntii,cumodificrileicompletrile
ulterioare.
Persoana mai sus menionat figureaz n evidenele noastre cu urmtorii
coasigurai(so/soie,prini,copiiaflainntreinere):
1.Nume,prenume,___________________________CNP__/__/__/__/__/__/__/__/__/__/__/__/__/
2.Nume,prenume,___________________________CNP__/__/__/__/__/__/__/__/__/__/__/__/__/
3.Nume,prenume,___________________________CNP__/__/__/__/__/__/__/__/__/__/__/__/__/
Prezentaadeverinareoperioaddevalabilitatede3lunideladataemiterii.
Sub sanciunile aplicate faptei de fals n acte publice, declar c datele din
adeverinsuntcorecteicomplete.
Semnturreprezentantlegal

NOT:Numruldeziledeconcediumedicaldecareangajatulabeneficiatnultimele12luni,vafimenionatpe
acestformularsaupeunformularseparat.

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