Ministre charg
du travail
N 15553*01
xxxxx*xx
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Le formulaire dattestation est tabli en deux exemplaires dont lun est remis au salari dtach afin dtre
conserv bord du moyen de transport avec lequel est assur le service et lautre est dtenu par lentreprise
daccueil du salari roulant ou navigant dtach.
The attestation form is drawn up in two copies, one is given to the posting worker to be kept in the vehicle which the
service is provided with, the other is kept by the borrowing company of the road or inland waterway transport mobile
worker.
Legal form
Adresse complte dans le pays dtablissement (n, voie, ville et pays): 307370,
___________________________
JUD. TIMIS,
Full address in country of establishment (number, street, postal code, town and country):
______________________________________________________________________________________
SAT.
SACALAZ, STR. A Vi-A, N 574/C
______________________________________________________________________________________
______________________________________________________________________________________
N de tlphone : _______________________
6 7 7 4 8 0 7 9 7
Telephone number:
Courriel :______________________________________________________________________________
INFOGICUEXPEDITION@GMAIL.COM
email :
Rfrences dimmatriculation au registre lectronique national des entreprises de transport par route
prvu par larticle 16 du rglement europen (CE) n 1071/2009 du 21 octobre 2009 :
______________________________________________________________________________________
RO-26908158
Registration number in the national electronic register of road transport undertakings (regulation (EC) n1071/2009 of 21 october
2009)
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Nom : RODILA
__________________________________ Prnom: GHEORGHE
____________________________________
Name:
First name:
Prnom : __________________
First name :
Adresse complte postale en France (n, voie, code postal et ville) : ______________________________
Full address in France (street number, postal code, town):
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
N de tlphone : _______________________
Telephone number:
Courriel :______________________________________________________________________________
Email :
Lump-Sum payement :
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Annexe
Appendix
INFORMATIONS RELATIVES AU SALARIE ROULANT OU NAVIGANT DETACHE
Information relating to the mobile posted worker
Cette annexe doit tre complte par lemployeur du salari roulant ou navigant dtach en France, quil soit
ressortissant de lUnion europenne ou dun Etat tiers.
The employer must complete this appendix for the mobile worker posted in France, whether he is a
Community or third-country national.
Nom : GROS
__________________________________ Prnom: COSMIN
_____________________________________
LUCIAN
Name:
First name:
ROMANIA
Lieu de naissance (ville et pays) : BISTRITA,
________________________
Date of birth :
Nationalit : ROMANIA
_______________
Nationality :
_______________________________________________________________________________________
_______________________________________________________________________________________
Date de signature du contrat de travail : _______________
15 / 1 1 / 15
Date of signature of work contract :
_____________________________________________________
SEGURIDAD
SOCIAL GIRONA
Qualification professionnelle : CONDUCTOR
_______________________________
MECANICO CAMION
Professional qualification :
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