..................................................... .......................................... 200... r.(pieczęć adresowa pracodawcy) (miejscowość i data)
ZAPIS
wyjaśnień informacji uzyskanych os świadka wypadku
Poszkodowany(a)
1. Imię i nazwisko: ....................................................................................................................... 2. Imię ojca: ..................................................................................................................................3. Data i miejsce urodzenia: .........................................................................................................4. Dowód osobisty (seria i nr): .....................................................................................................5. PESEL:......................................................................................................................................6. NIP:...........................................................................................................................................7. Miejsce zatrudnienia:................................................................................................................ 8. Stanowisko służbowe: ..............................................................................................................9. Adres zamieszkania: ................................................................................................................
Wyjaśnienia .……….………………………………………………………………………………………………………………………………………………………………………...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................………………………………………………………………………………………………..….
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