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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