1- Model -

CTREINSPECTORATUL GENERAL AL POLIIEI ROMNE

DIRECIA DE ORDINE PUBLIC

Subsemnatul(a)____________________________________________________, domiciliat()n ____________________________________________________________________________posesor al1 ____________________ seria ________, nr.___________________, eliberat de__________________________________ la data de ____________,______________________________, telefon _______________, fax ______________, email________________________, web _______________________________, v transmit documentelenecesare nscrierii n Registrul Naional al Evaluatorilor de Risc la Securitate Fizic.

Activitile de evaluare a riscurilor de securitate fizic se vor derula pentru angajatorul2_________________________________________________________________________, cu sediulsocial_______________________________________________ i administrativ_________________________________________________________, nmatriculat la O.R.C. cu numrul de ordine__________________________ i codul unic _________________, avnd ca activiti codurileCAEN3 7022 / 7112 / 7490, e-mail __________________________________________________,tel./fax ________________________________.

Competenele profesionale de evaluator au fost dobndite prin absolvirea cursului organizat deformatorul_______________________________________________________________________, nperioada_____________________, autorizat sub nr._____________________, desfurat nlocalitatea ____________________________________, cu susinerea examenului de absolvire n datade _____________, n prezena comisiei formate din: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

Anexez, urmtoarele documente4:

act de identitate ____________________ seria _______ nr._______________________ certificat de absolvire seria _________ nr. _____________ eliberat la data _______________ certificat de cazier judiciar nr. _______________ din _________________ certificat de nregistrare la ORC seria ________ nr. ___________________ certificat constatator emis de ORC nr. ________________ din ____________________ documente de atestare calitate angajat _____________________________________________________________________________________________________________________________________________________________________________________________________________________

Declar pe propria rspundere c datele menionate corespund realitii.

Data _____________ Semntura ___________

1 tip act de identitate (CI/paaport/permis edere)2 numele i datele de identificare ale angajatorului3 se taie opiunile care nu corespund4 documentele prevzute de art. 2 din Dispoziia I.G.P.R. nr. 73/2013