Wniosek o wydanie karty parkingowej

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Numer wniosku:
H,2,(;@>J;7(;1:/A67Q(
Wniosek o wydanie karty parkingowej
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1. Nazwa organu1
'6*25789*$2
DANE WNIOSKODAWCY
FD((&8:E
3. Nazwisko
4. Numer PESEL3
XD(%78?5(:(0,2,(;J0,1:,(/5=?3=?1:,(@/2;:?50=,4M3?K/(1:?@?>1/A@5,;1/<T
ADRES DO KORESPONDENCJI
8. Poczta4
RD(S:?4A3/;/<T(
7. Kod pocztowy
9. Ulica
10. Nr domu/Nr lokalu
)$&(*"+",-*+./$)$012(0*#&'"+(.5
CCD(&8:E
12. Nazwisko
13. Numer PESEL3
ADRES DO KORESPONDENCJI
16. Poczta4
COD(S:?4A3/;/<T(
15. Kod pocztowy
17. Ulica
18. Nr domu/Nr lokalu
)". 3(&4-*)"/125"&(*)"*#&'"+.
CUD(V/2/K5,P:,(/(;J8:,5,3W(LX(88(Y(OX(88
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(((FB(A@5,;74E(/@:?6E(1,0(/A/.M(1:?@?>1/A@5,;1MN(62I5,(4?A2(7@5,;1:/1,(0/(7=JA6,1:,(6,52J(@,56:1K/;?4
(((LB(A@5,;74E(675,2?-E(1,0(/A/.M(1:?@?>1/A@5,;1MN(62I5,(4?A2(7@5,;1:/1,(0/(7=JA6,1:,(6,52J(@,56:1K/;?4(
(((OB(0,1?(@/0,1?(;?(;1:/A67(AM(,627,-1?(:(=K/01?(=?(A2,1?8(P,62J3=1J8(
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23.
……………………………………………………
(data i podpis wnioskodawcy albo rodzica, opiekuna lub kuratora
,-./(,01/2,34,(/(.5,67(8/9-:;/<3:(=>/9?1:,(@/0@:A7B11
//1(+,234(6
12
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$9:*+-+>(,&9+,&/%(!?89&/+,!&%($!@</.!3+/(09$! ,/%<&%?!(;!8#0,9&/9(0/2(
24. Nazwa
25. Numer KRS
26. Numer REGON
27. R/931$1363(#1",-6*-$&'6"2!/$&.",8)+%
CN@$O"1+"$%$9'!3.$&'6"2!/$&.",8)+%
ADRES SIEDZIBY
31. Poczta4
CQ@$O%36(,')':D$
30. Kod pocztowy
32. Ulica
33. Nr domu/Nr lokalu
9&%(!0!6-(0")9 9:*+%:(.&/!0%"((
?>@$$I9%G
35. Nazwisko
36. Numer PESEL3
ADRES DO KORESPONDENCJI
39. Poczta4
?P@$O%36(,')':D$
38. Kod pocztowy
40. Ulica
41. Nr domu/Nr lokalu
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$$$C<$&.",8)+"$&1')"!2%$!2%";".*':D$)$2"+13(%3$'&%3+%7$13E"0%.%#",6%$./0$3!/+",6%$'(80$*%3&3;*'(&1")*-,E$9"6F,-,E$2*",2*%3$
$$$$$$$'41"*%,2'*3$9'5.%)':,%$("9'!2%3.*34'$&'1/(2"*%"$(%G$%$63(#$/&1")*%'*"$!'$/2-(+"*%"$+"1#-$&"1+%*4')36
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44.
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Potwierdzenie odbioru karty parkingowej
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uprawnionej do uzyskania karty parkingowej
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