!"#$%&'()*+'%( Numer wniosku: H,2,(;@>J;7(;1:/A67Q(
Wniosek o wydanie karty parkingowej !"#$%&'( %&)Z[)H' \' 1. Nazwa organu1
'6*25789*$2 DANE WNIOSKODAWCY FD((&8:E
3. Nazwisko
4. Numer PESEL3
XD(%78?5(:(0,2,(;J0,1:,(/5=?3=?1:,(@/2;:?50=,4M3?K/(1:?@?>1/A@5,;1/<T
ADRES DO KORESPONDENCJI 8. Poczta4
RD(S:?4A3/;/<T(
7. Kod pocztowy
9. Ulica
10. Nr domu/Nr lokalu
)$&(*"+",-*+./$)$012(0*#&'"+(.5 CCD(&8:E
12. Nazwisko
13. Numer PESEL3 ADRES DO KORESPONDENCJI 16. Poczta4
COD(S:?4A3/;/<T(
15. Kod pocztowy
17. Ulica
18. Nr domu/Nr lokalu
)". 3(&4-*)"/125"&(*)"*#&'"+. CUD(V/2/K5,P:,(/(;J8:,5,3W(LX(88(Y(OX(88
6
FGD(H/;I0(7:A=3=?1:,(/@>,2J(=,(;J0,1:?(6,52J(@,56:1K/;?4(:(/@>,2J(?;:0?13J41?4 7
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…………………………………………………… (data i podpis wnioskodawcy albo rodzica, opiekuna lub kuratora ,-./(,01/2,34,(/(.5,67(8/9-:;/<3:(=>/9?1:,(@/0@:A7B11
//1(+,234(6
12
9&%(;<9+7."/(,9:$#:*+%:(0/2(!;/%"*=(8%>96/</'9+:*(<#6(% #"9+:*(!076(&/%;%)&!0;89.&-+>( $9:*+-+>(,&9+,&/%(!?89&/+,!&%($!@</.!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%"(( ?>@$$I9%G
35. Nazwisko
36. Numer PESEL3 ADRES DO KORESPONDENCJI 39. Poczta4
?P@$O%36(,')':D$
38. Kod pocztowy
40. Ulica
41. Nr domu/Nr lokalu
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…………………………………………………… !"#"$%$&'!&%($'('0-$/&')"5*%'*36$!'$$13&1323*#')"*%"$&.",8)+%$ ".0'$"!*'#",6"$'$01"+/$9'5.%)':,%$2;'53*%"$&'!&%(/<11
///1(+,234(+(5(! 6/78("98'-( Potwierdzenie odbioru karty parkingowej '#12-9";39J'#12-9";"910
>K@$L"1#G$&"1+%*4')F$*/931B$ !"#$%&'()*+(,-#./6: $$$=<$&'(%"!"9$/&')"5*%3*%3$!'$13&1323*#')"*%"$&.",8)+%$ uprawnionej do uzyskania karty parkingowej ###01#234(&567#&8()+7#49)+'*'/:2;<-#93'/;7#:5=#;54(>/:7#?()#929=<# #######?'/3/8?9234(&?<#534(&?'9?<#)9#5+@2;(?'(#;(4>@#3(4;'?A9&/6
47.
…………………………………………………… !"#"$%$&'!&%($)*%'(+'!"),-$./0$'('0-$&1232$*%34'$/&')"5*%'*36$ ".0'$1'!2%,"7$'&%3+/*"$./0$+/1"#'1"7$".0'$'('0-$/&')"5*%'*36$!'$$ 13&1323*#')"*%"$&.",8)+%$".0'$"!*'#",6"$'$01"+/$9'5.%)':,%$ 2;'53*%"$&'!&%(/<
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IQRS&HT;HUVW13
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2
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3
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