zgłoszenie pobytu czasowego

=*à26=(1,(32%<78&=$62:(*2/
TEMPORARY RESIDENCE REGISTRATION FORM
1. NU0(53(6(/2,/(=267$à1$'$1<PESEL NUMBER (IF IT WAS ISSUED)
2. NAZWISKO/SURNAME
,0,ĉ (IMIONA)/NAME (NAMES)
4. DATA URODZENIA (dd/mm/rrrr)/DATE OF BIRTH (dd/mm/yyyy)
-
-
5. MIEJSCE URODZENIA/PLACE OF BIRTH
6. KRAJ URODZENIA/COUNTRY OF BIRTH
7$'5(60,(-6&$32%<7867$à(*2ADDRESS OF THE PLACE OF PERMANENT RESIDENCE*
KOD POCZTOWY/POSTAL CODE
MIE-6&2:2ĝû– DZIELNICA/CITY – CITY DISTRICT
GMINA/COMMUNE
:2-(:Ï'=7:2VOIVODESHIP
ULICA/STREET
NUMER DOMU/HOUSE NUMBER
NUMER LOKALU/FLAT NUMBER
8. ADRES DOTYCHCZASOWEGO MIEJSCA POBYTU CZASOWEGO*/ADDRESS OF THE PREVIOUS PLACE OF TEMPORARY
RESIDENCE*
KOD POCZTOWY/POSTAL CODE
0,(-6&2:2ĝû– DZIELNICA/CITY – CITY DISTRICT
WOJEWÓDZTWO/VOIVODESHIP
GMINA/COMMUNE
ULICA/STREET
NUMER DOMU/HOUSE NUMBER
NUMER LOKALU/FLAT NUMBER
9. ADRES NOWEGO MIEJSCA POBYTU CZASOWEGO/ADDRESS OF THE NEW PLACE OF TEMPORARY RESIDENCE
KOD POCZTOWY/POSTAL CODE
MIEJSCOWOĝû– DZIELNICA/CITY – CITY DISTRICT
WOJEWÓDZTWO/VOIVODESHIP
GMINA/COMMUNE
ULICA/STREET
NUMER DOMU/HOUSE NUMBER
NUMER LOKALU/FLAT NUMBER
10. DEKLAROWANY OKRES POBYTU/PERIOD OF INTENDED STAY
OD/FROM
DO/TO
11. 1$ZW,6.O,,0,ĉ3Eà1O0O&1,.$/ SURNAME AND FIRST NAME OF THE PROXY**
6WZLHUG]DPĪHZ\ĪHMZ\PLHQLRQDRVRED przebywa pod wskazanym adresem/I hereby confirm that the above-mentioned person stays at the address provided
………………………………..
PLHMVFRZRĞüGDWD(place, date)
…………….…………………………………………
ZáDVQRUĊF]Q\F]\WHOQ\SRGSLVZáDĞFLFLHODORNDOX
OXELQQHJRSRGPLRWXG\VSRQXMąFHJRW\WXáHPSUDZQ\PGRlokalu)/
(handwritten legible signature of the owner of the flat or a person
who holds a legal title to the flat)
6WZLHUG]DPZLDU\JRGQRĞüSRZ\ĪV]\FKGDQ\FK/,KHUHE\FHUWLI\WKDWWKe above information is true and correct
………..………………………………..
….…………...……..……………………….…….
PLHMVFRZRĞüGDWD(place, date)
ZáDVQRUĊF]Q\F]\WHOQ\SRGSLVRVRE\]JáDV]DMąFHM/
(handwritten legible signature of the applicant)
POUCZENIE/INSTRUCTION
ZJáRV]HQLHQDOHĪ\Z\SHáQLüZMĊ]\NXSROVNLPNRPSXWHURZRPDV]\QRZROXESLVPHPRGUĊF]Q\PNRORUHPQLHELHVNLPOXEF]DUQ\PGUXNRZDQ\PLOLWHUDPL./
Complete the application form in Polish by typing (printing) or in handwriting, in blue or black using capital letters.
* W przypadku braku dotychczasRZHJRPLHMVFDSRE\WXSR]RVWDZLDVLĊSXVWHSROH./If there is no previous place of stay, leave the box blank.
:\SHáQLüZSU]\SDGNXZ\NRQ\ZDQLDRERZLą]NXPHOGXQNRZHJRSU]H]SHáQRPRFQLND./Complete if the registration requirement is performed by a proxy.
C]ĊĞüÄ%´Z\SHáQLDXU]ĊGQLN/Section B to be completed by an official
PrzyjĊWR]JáRV]HQLHSRE\WXF]DVRZHJRThe temporary residence registration form is hereby accepted
………………………………………………
PLHMVFRZRĞüGDWD(place, date)
……….…………………………………………………………
SLHF]ĊüLSRGSLVXU]ĊGQLNDSU]\MPXMąFHJR]JáRV]HQLHSRE\WXF]DVRZHJR/
(seal and signature of the official accepting the temporary residence registration form)