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\par }{\f28 Nazwisko i Imi\'ea / Jednostka: ......................... ..................................................... \par }{\lang1031\langfe1045\langnp1031 Nr PESEL / REGON:............................................................................................ \par }{Adres: ...................................................................... \par Nr telefonu: .............................................................. \par }\pard \s15\qc \li0\ri-290\sb100\sa100\sbauto1\saauto1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin-290\lin0\itap0 {\b WNIOSEK \par }\pard \s15\qc \li0\ri0\sb100\sa100\sbauto1\saauto1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\b\f28 O UDOST\'caPNIENIE INFORMACJI PUBLICZNEJ \par }\pard \s15\ql \li0\ri-650\sb100\sa100\sbauto1\saauto1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin-650\lin0\itap0 {\f28 Na podstawie art. 2 ust. 1 ustawy o dost\'eapie do informacji publicznej z dnia 6 wrze\'9c nia 2001 r. 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\li0\ri0\sb100\sa100\sbauto1\saauto1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\b\f28 SPOS\'d3B I FORMA UDOST\'caPNIENIA INFORMACJI:* \par }\trowd \trgaph70\trleft-70\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl70\trpaddr70\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4930 \cellx4860\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1800 \cellx6660\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2480 \cellx9140\pard \s15\ql \li0\ri0\sb100\sa100\sbauto1\saauto1\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\b \u1649\'3f}{\f28 dost\'eap do przegl\'b9dania informacji w urz\'ead}{zie}{\b \cell \u1649\'3f}{ kserokopia}{\b \cell \u1649\'3f }{ pliki komputerowe}{\b \cell }\pard\plain \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs24\lang1045\langfe1045\cgrid\langnp1045\langfenp1045 {\b \trowd \trgaph70\trleft-70\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl70\trpaddr70\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4930 \cellx4860\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1800 \cellx6660\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2480 \cellx9140\row }\pard\plain \s15\ql \li0\ri0\sb100\sa100\sbauto1\saauto1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1045\langfe1045\cgrid\langnp1045\langfenp1045 {\b\f28 RODZAJ NO\'8cNIKA: \par }\trowd \trgaph70\trleft-70\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl70\trpaddr70\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2950 \cellx2880\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660 \cellx5540\pard\plain \ql \li360\ri0\sb100\sa100\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin360 \fs24\lang1045\langfe1045\cgrid\langnp1045\langfenp1045 {\b \u1649\'3f }{ dyskietka 3,5 }{\b \cell \u1649\'3f }{ CD-ROM }{\b \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\b \trowd \trgaph70\trleft-70\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl70\trpaddr70\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2950 \cellx2880\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl \brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660 \cellx5540\row }\pard\plain \s15\ql \li0\ri0\sb240\sa100\sbauto1\saauto1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1045\langfe1045\cgrid\langnp1045\langfenp1045 {\b FORMA PRZEKAZANIA INFORMACJI: \par }\pard\plain \ql \li357\ri0\sl360\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin357\itap0 \fs24\lang1045\langfe1045\cgrid\langnp1045\langfenp1045 {\b \u1649\'3f}{\f28 Przes\'b3anie informacji poczt\'b9 elektroniczn\'b9 pod adres .................................................... \par }\pard\plain \s17\ql \fi-363\li720\ri0\sl360\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0 \fs24\lang1045\langfe1045\cgrid\langnp1045\langfenp1045 {\b \u1649\'3f}{\f28 Przes\'b3anie informacji poczt\'b9 pod adres** ...................................................................... \line .......................................................................................................................................... \par }\pard\plain \ql \li357\ri0\sl360\slmult1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin357\itap0 \fs24\lang1045\langfe1045\cgrid\langnp1045\langfenp1045 {\b \u1649\'3f}{\f28 Odbi\'f3r osobi\'9ccie przez wnioskodawc\'ea \par }\pard\plain \s18\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1045\langfe1045\cgrid\langnp1045\langfenp1045 {\f28 Wyra\'bfam zgod\'ea na przetwarzanie moich danych osobowych zgodnie z ustaw\'b9 o ochronie danych osobowych z dnia 29.08.1997 r. (Dz.U. .Nr 133 poz 883.z p\'f3\'9fn. zm.) \par }\pard\plain \s15\ql \fi708\li4956\ri0\sb100\sa100\sbauto1\saauto1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin4956\itap0 \fs24\lang1045\langfe1045\cgrid\langnp1045\langfenp1045 { \par }\pard \s15\ql \fi-4956\li4956\ri0\sb100\sbauto1\saauto1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin4956\itap0 {.....................................................\tab \tab ........................................................ \par }\pard \s15\ql \fi-4248\li4956\ri0\sa100\sbauto1\saauto1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin4956\itap0 {\f28 Miejscowo\'9c\'e6, data \tab \tab \tab podpis wnioskodawcy \par }\pard \s15\ql \li0\ri0\sbauto1\saauto1\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\fs22 Uwagi: \par }{\f28\fs22 * prosz\'ea zakre\'9cli\'e6 w\'b3a\'9cciwe pole krzy\'bfykiem \par ** wype\'b3ni\'e6 je\'9cli adres jest inny ni\'bf podany wcze\'9cniej \par }\pard\plain \s16\ql \li0\ri0\sb120\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \b\fs24\lang1045\langfe1045\cgrid\langnp1045\langfenp1045 {\f28 Urz\'b9d zastrzega prawo pobrania op\'b3aty od informacji udost\'eapnionych zgodnie z art . 15 ustawy o dost\'eapie do informacji publicznej \par }}