CERERE REZILIERE CONTRACT - gazest.ro

[Pages:1]CERERE REZILIERE CONTRACT

Nr. ?nregistrare: ........... /...........................

Persoan fizic

Persoan juridic

Asociaie de proprietari/locatari

[............................................................................................................] [.......................................................] [...........................................................]

Solicitant

Cod abonat

Identificat prin CNP / CUI / CIF

[........................................] [...........................................] [............................................................] [......]

Adresa: Judeul

Localitatea

Strada

Nr.

[.......] [.......] [.........] [..........]

Bloc

Scara Etaj

Apt.

[..........................................] [..........................................] [...........................................] [.........................................................................................]

Tel. fix

Tel. mobil

Fax

Email

[........................................................................................................................................................................................................................................] Reprezentant legal (*numai ?n cazul persoanelor juridice i al asociaiilor de proprietari)

Solicit rezilierea contractului de furnizare nr. [............................................] ?ncep?nd cu data de [ ............. / ............. / .................... ]

Motivul rezilierii contractului: schimbarea domiciliului

Altele: [.....................................................................................................................................................]

Indexul contorului de msurare la data rezilierii contractului:

[...........................................................] Seria contorului

[.......................................................] Index contor necorectat

[.......................................................] Index contor corectat

[ ............. / ............. / .................... ] Data

[.......................................................] Semntura solicitantului

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