Către,
Inspectoratul Teritorial de Muncă Cluj

         Subsemnatul(a)__________________________________născut(ă) la data de __________________ CNP_________________________________domiciliat(ă) în loc__________________________________ str.__________________________________, nr._____,bl._____, sc._____,ap.___, jud.________________ tel__________________, am lucrat în perioada ______________--______________ în functia de ________ ____________________la angajatorul (firma) _____________________________________, cu sediul în loc. _______________________________________, str.______________________________, nr._____, bl._____, sc._____, ap.______,jud.________________, tel._____________________________, cu punct de lucru în localitatea ________________________________, str.______________________________, nr._____, bl._____, sc._____, ap.______,jud.________________, tel____________________________, reprezentată prin (nume şi prenume patron) ___________________________________, domiciliat în loc.______________________ str.______________________________, nr._____, bl._____, sc._____, ap.______,jud.________________tel._________________________.
	În cele ce urmează vă relatez următoarele:_______________________________________________
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** Notă: Se va anexa copia actului de identitate
	Cluj-Napoca								Semnătura
	Data ____________