Denumire/ Nume, Prenume |_________________________________________________________| Cod de identificare fiscală RO |_|_|_|_|_|_|_|_|_|_| Domiciliul fiscal Judeţ |__________| Localitate |____________| Strada |_____________________| Număr |__| Bloc |_| Scara |____| Ap. |___| Cod poştal |_____________________| Sector |____| Telefon |______________| Fax |___________________| E-mail |_______________________| Nr. act împuternicire |______________________| Data |______________| |