ANEXA 3

    Seria ........ nr. ...........

                                    ROMÂNIA

               MINISTERUL MUNCII, FAMILIEI SI PROTECTIEI SOCIALE

       INSPECTORATUL TERITORIAL DE MUNCA ...............................

                      CERTIFICAT CONSTATATOR Nr. ........

    emis în temeiul art. 13 lit. c) din Legea securitatii si sanatatii în munca nr. 319/2006 si art. 6 alin. (1) lit. b) din Legea nr. 108/1999 pentru înfiintarea si organizarea Inspectiei Muncii, republicata, eliberat în baza declaratiei pe propria raspundere, înregistrata sub nr. ....... din ...................., pentru:

    Persoana juridica: ................................., cu sediul social în localitatea ........................., str. ..................... nr. ....., bl. ...., sc. ...., et. ...., ap. ...., judetul/sectorul ................

    Prezentul certificat constatator atesta ca s-a înregistrat declaratia pe propria raspundere conform careia persoana juridica îndeplineste conditiile de functionare din punct de vedere al securitatii si sanatatii în munca pentru activitatea/activitatile declarate:

*T*

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¦Nr. ¦    Denumirea activitatii     ¦   Cod   ¦      Adresa la care se     ¦

¦crt.¦                              ¦   CAEN  ¦    desfasoara activitatea  ¦

+----+------------------------------+---------+----------------------------¦

¦    ¦                              ¦         ¦                            ¦

+----+------------------------------+---------+----------------------------¦

¦    ¦                              ¦         ¦                            ¦

+----+------------------------------+---------+----------------------------¦

¦    ¦                              ¦         ¦                            ¦

+----+------------------------------+---------+----------------------------¦

¦    ¦                              ¦         ¦                            ¦

+----+------------------------------+---------+----------------------------¦

¦    ¦                              ¦         ¦                            ¦

+----+------------------------------+---------+----------------------------¦

¦    ¦                              ¦         ¦                            ¦

+----+------------------------------+---------+----------------------------¦

¦    ¦                              ¦         ¦                            ¦

+----+------------------------------+---------+----------------------------¦

¦    ¦                              ¦         ¦                            ¦

+--------------------------------------------------------------------------+

*ST*

                                 Inspector-sef,

                              ....................

    Data eliberarii:

    ziua ..... luna ........... anul .......

                                                                - verso -

*T*

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¦Nr. ¦ Denumirea  ¦ Cod  ¦ Adresa la care¦    Semnatura     ¦    Semnatura     ¦

¦crt.¦activitatii ¦ CAEN ¦ se desfasoara ¦inspectorului-sef/¦inspectorului-sef/¦

¦    ¦            ¦      ¦ activitatea   ¦  Data sistarii   ¦   Data reluarii  ¦

¦    ¦            ¦      ¦               ¦   activitatii    ¦    activitatii   ¦

+----+------------+------+---------------+------------------+------------------¦

¦    ¦            ¦      ¦               ¦                  ¦                  ¦

+----+------------+------+---------------+------------------+------------------¦

¦    ¦            ¦      ¦               ¦                  ¦                  ¦

+----+------------+------+---------------+------------------+------------------¦

¦    ¦            ¦      ¦               ¦                  ¦                  ¦

+----+------------+------+---------------+------------------+------------------¦

¦    ¦            ¦      ¦               ¦                  ¦                  ¦

+----+------------+------+---------------+------------------+------------------¦

¦    ¦            ¦      ¦               ¦                  ¦                  ¦

+----+------------+------+---------------+------------------+------------------¦

¦    ¦            ¦      ¦               ¦                  ¦                  ¦

+----+------------+------+---------------+------------------+------------------¦

¦    ¦            ¦      ¦               ¦                  ¦                  ¦

+------------------------------------------------------------------------------+