Приложение 1. Анкета зарегистрированного лица (Форма АДВ-1)

Анкета зарегистрированного лица

Заполняется зарегистрированным лицом печатными буквами

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│Фамилия ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│Имя ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│Отчество (при наличии) ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│Пол ._. (м/ж) │

│Дата рождения "._._." ._._._._._._._._. ._._._._. года │

│Место рождения: │

│ город (село, деревня, ...) ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ район ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ регион (область, край, республика, ...) ._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ страна ._._._._._._._._._._._._._._._._._._._._._. │

│Гражданство ._._._._._._._._._._._._._._._._._._._._._. │

│Адрес индекс ._._._._._._. адрес ._._._._._._._._._._. │

│регистрации ._._._._._._._._._._._._._._._._._._._._._._. │

│ ._._._._._._._._._._._._._._._._._._._._._._. │

│Адрес места индекс ._._._._._._._. адрес ._._._._._._._._._._. │

│жительства ._._._._._._._._._._._._._._._._._._._._._._. │

│фактический ._._._._._._._._._._._._._._._._._._._._._._. │

│ (заполнять при отличии от адреса регистрации) │

│Телефоны ._._._._._._._._._._._._._._._._._._._._._._. │

│ (домашний и/или рабочий) │

│Документ, удостоверяющий личность │

│Вид документа ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ (указать название документа: паспорт, удостоверение личности или другие │

│ документы, удостоверяющие личность) │

│Серия, номер ._._._._._._._._._._._._._._._._._._._. │

│Дата выдачи "._._." ._._._._._._._._. ._._._._. года │

│Кем выдан ._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ ._._._._._._._._._._._._._._._._._._._._._._._._._. │

│Реквизиты акта гражданского состояния о рождении: │

│Номер актовой записи о рождении ._._._._._._._._._._._._._._._._._._._._._._._._._. │

│Дата составления актовой записи о рождении "._._." ._._._._._._._._. ._._._._. года │

│Наименование органа, которым произведена государственная регистрация акта о рождении ._._._._._._._._._.│

│._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│Идентификационный номер налогоплательщика (при наличии) ._._._._._._._._._._._._._._._. │

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Дата заполнения Подпись зарегистрированного лица

(представителя)

"._._." ._._._._._._._._. ._._._._. года ________________________________