Operator de date cu caracter personal

$PEDVDGD5RPkQLHLOD
&KLúLQăX

1UvQUHJLVWUDUH Data:
27.11.2018

Cod de cerere SIMISC: PE2620231

CERERE
de prestare a unui serviciu consular

1. DATELE DE IDENTIFICARE ALE SOLICITANTULUI

1.1. Numele de Numele de familie actual: Numele de familie la QD‫܈‬WHUH: Alte nume de familie anterioare:
familie:
HORTOLOMEI
1.2. Prenumele: Prenumele actual: 3UHQXPHOHODQD‫܈‬WHUH: Alte prenume anterioare:

IVAN
&HWă‫܊‬HQLD 1.4. Codul numeric personal:
REPUBLICA
MOLDOVA
1.5. Sexul:
MASCULIN Localitatea: SALCIA
'DWDQD‫܈‬WHULL 0 8 0 5 1 9 9 0 /RFXOQD‫܈‬WHULL
-XGH‫܊‬XO6HFWRUXO TARACLIA
Ziua Luna Anul
‫܉‬DUD REPUBLICA MOLDOVA
3D‫܈‬DSRUWVLPSOX 3D‫܈‬DSRUWVLPSOX 3D‫܈‬DSRUWVLPSOX 7LWOXGHFăOăWRULH
electronic temporar
Carte de identitate Buletin de Carte de identitate 3D‫܈‬DSRUWGLSORPDWLF
'RFXPHQWXOGH identitate provizorie
identitate 3D‫܈‬DSRUWGHVHUYLFLXHOHFWURQLF x Alt document:
$XWRULWDWHDHPLWHQWă 'DWDHOLEHUăULL 'DWDH[SLUăULL
0 2 0 4 2 0 1 8 0 8 0 5 2 0 3 5
ASP Ziua Luna Anul Ziua Luna Anul
‫܉‬DUD Localitatea: -XGH‫܊‬XO6HFWRUXO5HJLXQHD
1.9.Domiciliul legal:
REPUBLICA MOLDOVA SALCIA
(conform documentelor Strada: Nr.: Bloc: Apartament: &RGSR‫܈‬WDO
GHLGHQWLWDWHURPkQH‫܈‬WL

5H‫܈‬HGLQ‫܊‬D ‫܉‬DUD Localitatea: -XGH‫܊‬XO6HFWRUXO5HJLXQHD

DFWXDOă
REPUBLICA MOLDOVA CHISINAU
GDFăGLIHUăGH Strada: Nr.: Bloc: Apartament: &RGSR‫܈‬WDO
adresa de domiciliu)

NICOLAE TESTEMITANU 24 2 CAMIN

1XPăUGH $GUHVăGHHPDLO
telefon: +37360099176 nutzyk@gmail.com

1/3
 2. SERVICIUL CONSULAR SOLICITAT
2.1. Obiectul
'(&/$5$‫܉‬,,
cererii:
2.2. Tipul '(&/$5$ğ,(5('2%Æ1',5(&(7Ă7(1,(
1XPăUXOGHGXSOLFDWHGRULW 1
documentului: DOMICILIU - 1 DUPLICAT

3.3527(&‫܉‬,$'$7(/25&8&$5$&7(53(5621$/

3.,QIRUPDUHSULYLQGUHJLPXOSURWHF‫܊‬LHLGDWHORUFXFDUDFWHUSHUVRQDOFROHFWDWHSULQSUH]HQWDFHUHUH

0LQLVWHUXO$IDFHULORU([WHUQHvQFDOLWDWHGHRSHUDWRUGHGDWHFXFDUDFWHUSHUVRQDOFXVHGLXOvQ$OHHD$OH[DQGUXQU6HFW%XFXUH‫܈‬WL
SUHOXFUHD]ăGDWHFXFDUDFWHUSHUVRQDOvQH[HUFLWDUHDSUHURJDWLYHORUGHDXWRULWDWHSXEOLFD‫܈‬LvQVWULFWăFRQIRUPLWDWHFXSUHYHGHULOH
5HJXODPHQWXOXL*HQHUDOSULYLQGSURWHF‫܊‬LDGDWHORU 5*3' 
'DWHOHFXFDUDFWHUSHUVRQDOVROLFLWDWHSULQSUH]HQWXOIRUPXODUYRUILSXVHODGLVSR]L‫܊‬LDDXWRULWă‫܊‬LORUURPkQHFRPSHWHQWH '(3$%''*3
81135$1&'35&,9SUHFXP‫܈‬LDOWRUDXWRULWă‫܊‬LFRPSHWHQWH ‫܈‬LSURFHVDWHGHFăWUHDFHVWHDGXSăFD]vQVFRSXOOXăULLXQHLGHFL]LLFXSULYLUH
ODVROLFLWDUHDGYVGHSUHVWDUHDVHUYLFLXOXLFRQVXODU$FHVWHGDWHVXQWLQWURGXVH‫܈‬LVWRFDWHvQED]HOHGHGDWHDFFHVLELOHDXWRULWă‫܊‬LORUURPkQH
competente.
9ăSXWH‫܊‬LH[HUFLWDGUHSWXOGHDFFHVGHUHFWLILFDUHGHúWHUJHUHDGDWHORUVDXGHUHVWULFĠLRQDUHDSUHOXFUăULLRULDGUHSWXOXLGHDYăRSXQH
SUHOXFUăULLSUHFXPúLDGUHSWXOXLODSRUWDELOLWDWHDGDWHORUvQFRQGL‫܊‬LLOHSUHYă]XWHGH5*3'SULQWURFHUHUHVFULVăGDWDWă‫܈‬LVHPQDWăDGUHVDWă
PLVLXQLLGLSORPDWLFHVDXRILFLXOXLFRQVXODUFDUHSUHLD‫܈‬LSURFHVHD]ăSUH]HQWDVROLFLWDUHVDX0LQLVWHUXOXL$IDFHULORU([WHUQHDO5RPkQLHL'H
DVHPHQHDYăLQIRUPăPFăYăSXWH‫܊‬LUHWUDJHFRQVLPĠăPkQWXOvQRULFHPRPHQWIăUăDDIHFWDOHJDOLWDWHDSUHOXFUăULLHIHFWXDWHSHED]D
FRQVLPĠăPkQWXOXLvQDLQWHGHUHWUDJHUHDDFHVWXLD
ÌQFD]XOvQFDUHFRQVLGHUD‫܊‬LFăSUHOXFUDUHDGDWHORUFXFDUDFWHUSHUVRQDOFDUHYăYL]HD]ăvQFDOFăSUHYHGHULOH5*3'DYH‫܊‬LGUHSWXOGHDGHSXQHR
SOkQJHUHvQID‫܊‬DRSHUDWRUXOXLVDXvQID‫܊‬DDXWRULWă‫܊‬LLGHVXSUDYHJKHUH
6WUXFWXUDUHVSRQVDELOăGLQFDGUXO0$(FXLPSOHPHQWDUHDPăVXULORUvQGRPHQLXOSURWHF‫܊‬LHLSHUVRDQHORUFXSULYLUHODSUHOXFUDUHDGDWHORUHVWH
2ILFLXOUHVSRQVDELOXOXLFXSURWHF‫܊‬LDGDWHORUFDUHSRDWHILFRQWDFWDWODDGUHVDGHFRUHVSRQGHQ‫܊‬ăGSR#PDHURUHVSHFWLYODXUPăWRDUHOHQXPHUH
de telefon: tel: +40 21 431 11 00; +40 21 431 15 62; +40 21 319 21 08 ; +40 21 319 21 25.

3.'HFODUD‫܊‬LDVROLFLWDQWXOXLSULYLQGGDWHOHFXFDUDFWHUSHUVRQDOIXUQL]DWHSULQSUH]HQWDFHUHUH

6XEVHPQDWXO6XEVHPQDWDGHFODUSHSURSULDUăVSXQGHUHFăDPIRVWLQIRUPDWFXSULYLUHODGLVSR]LĠLLOH5*3'UHIHULWRDUHOD
LGHQWLWDWHD‫܈‬LGDWHOHGHFRQWDFWDOHRSHUDWRUXOXL
GDWHOHGHFRQWDFWDOHUHVSRQVDELOXOXLFXSURWHF‫܊‬LDGDWHORU
VFRSXULOHvQFDUHVXQWSUHOXFUDWHGDWHOHFXFDUDFWHUSHUVRQDOSUHFXP‫܈‬LWHPHLXOMXULGLFDOSUHOXFUăULL
- destinatarii sau categoriile de destinatari;
FDUDFWHUXOREOLJDWRULXRSĠLRQDODOGDWHORUFDUHWUHEXLHIXUQL]DWHSULQLQWHUPHGLXOIRUPXODUHORUGHVROLFLWDUHDVHUYLFLLORUFRQVXODUH
H[LVWHQĠDGUHSWXOXLGHDVROLFLWDRSHUDWRUXOXLvQFHHDFHSULYHúWHGDWHOHFXFDUDFWHUSHUVRQDOUHIHULWRDUHODSHUVRDQDYL]DWăDFFHVXOOD
DFHVWHDUHFWLILFDUHDVDXúWHUJHUHDDFHVWRUDVDXUHVWULFĠLRQDUHDSUHOXFUăULLVDXDGUHSWXOXLGHDVHRSXQHSUHOXFUăULLSUHFXPúLDGUHSWXOXLOD
portabilitatea datelor;
H[LVWHQĠDGUHSWXOXLGHDUHWUDJHFRQVLPĠăPkQWXOvQRULFHPRPHQWIăUăDDIHFWDOHJDOLWDWHDSUHOXFUăULLHIHFWXDWHSHED]DFRQVLPĠăPkQWXOXL
vQDLQWHGHUHWUDJHUHDDFHVWXLD
GUHSWXOGHDGHSXQHRSOkQJHUHvQIDĠDXQHLDXWRULWăĠLGHVXSUDYHJKHUH
FRQVHFLQĠHOHUHIX]XOXLGHDOHIXUQL]DQHIXUQL]DUHDVHUYLFLXOXLFRQVXODU
ÌQDFHVWVHQVvPLH[SULPDFRUGXOFXSULYLUHODSUHOXFUDUHDGDWHORUFXFDUDFWHUSHUVRQDOvQVFULVHvQSUH]HQWDVROLFLWDUHvQYHGHUHDSUHVWăULL
VHUYLFLXOXLFRQVXODU‫܈‬LGHFODUSHSURSULDUăVSXQGHUHFăDFHVWHGDWHFRUHVSXQGUHDOLWăĠLL
0HQĠLRQH]FăvQH[SULPDUHDFRQVLPĠăPkQWXOXLQXDPIRVWLQIOXHQĠDWVDXFRQVWUkQVVHQVvQFDUHvPLH[SULPDFRUGXOOLEHUúLvQFXQRúWLQĠăGH
FDX]ă

'HFODUFăDPIRVWLQIRUPDWFăDPGUHSWXOVăvPLUHWUDJvQRULFHPRPHQWFRQVLP‫܊‬ăPkQWXO5HWUDJHUHDFRQVLP‫܊‬ăPkQWXOXLQXDIHFWHD]ăOHJDOLWDWHD
SUHOXFUăULLHIHFWXDWHSHED]DFRQVLP‫܊‬ăPkQWXOXLvQDLQWHGHUHWUDJHUHDDFHVWXLD

2/3
 4.'$7$‫܇‬,/2&8/&203/(7Ă5,,6(01Ă785$

4.'DWDFRPSOHWăULLFHUHULL

Ziua Luna Anul

4./RFXOFRPSOHWăULLFHUHULL 0LVLXQHDGLSORPDWLFă2ILFLXO Localitatea: ‫܉‬DUD

consular:

$0%$6$'$520Æ1,(,/$ &+,ù,1Ă8 REPUBLICA MOLDOVA

4.6HPQăWXUDVROLFLWDQWXOXL

3/3