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{\title Dolno\'9cl\'b9ski Urz\'b9d Wojew\'f3dzki }{\author Dolno\'9cl\'b9ski Urz\'b9d Wojew\'f3dzki}{\operator Nina Zwierz}{\creatim\yr2004\mo3\dy3\hr14\min58}{\revtim\yr2004\mo3\dy3\hr14\min58}{\printim\yr2002\mo3\dy4\hr13\min58}{\version2}{\edmins0}
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\s15\qr\li720\sb100\sa100\nowidctlpar\widctlpar\adjustright \lang1045\cgrid {\b\fs20 
\par }\pard \s15\sb100\sa100\nowidctlpar\widctlpar\adjustright {\fs20 DANE WNIOSKODAWCY
\par }{\f20\fs20 Nazwisko i Imi\'ea / Jednostka: ......................... .....................................................
\par }{\fs20\lang1031 Nr PESEL / REGON:............................................................................................
\par }{\fs20 Adres: ......................................................................
\par Nr telefonu: ..............................................................
\par }\pard \s15\qc\ri-290\sb100\sa100\nowidctlpar\widctlpar\adjustright {\b\fs20 WNIOSEK
\par }\pard \s15\qc\sb100\sa100\nowidctlpar\widctlpar\adjustright {\b\f20\fs20 O UDOST\'caPNIENIE INFORMACJI PUBLICZNEJ
\par }\pard \s15\ri-650\sb100\sa100\nowidctlpar\widctlpar\adjustright {\f20\fs20 Na podstawie art. 2 ust. 1 ustawy o dost\'eapie do informacji publicznej z dnia 6 wrze\'9cnia 2001 r. (Dz. U. Nr 112, poz. 1198) zwracam si\'ea z pro\'9cb\'b9 o udost\'ea
pnienie informacji w nast\'eapuj\'b9cym zakresie:
\par }{\fs20 ..................................................................................................................................................................
\par ..................................................................................................................................................................
\par ..................................................................................................................................................................
\par ..................................................................................................................................................................
\par ..................................................................................................................................................................
\par }\pard \s15\sb100\sa100\nowidctlpar\widctlpar\adjustright {\b\f20\fs20 SPOS\'d3B I FORMA UDOST\'caPNIENIA INFORMACJI:*
\par }\trowd \trgaph70\trleft-70\trkeep\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 
\clbrdrr\brdrs\brdrw10 \cltxlrtb \cellx4860\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb \cellx9140\pard \s15\li360\sb100\sa100\nowidctlpar\widctlpar\intbl\adjustright {\b\fs20 \u8300\'3f}{
\f20\fs20   dost\'eap do przegl\'b9dania informacji w urz\'eadzie}{\b\fs20 \cell \u8300\'3f  }{\fs20 kserokopia}{\b\fs20 \cell }\pard\plain \nowidctlpar\widctlpar\intbl\adjustright \lang1045\cgrid {\b\fs20 \row }\pard\plain 
\s15\sb100\sa100\nowidctlpar\widctlpar\adjustright \lang1045\cgrid {\b\f20\fs20 RODZAJ NO\'8cNIKA:
\par }\trowd \trgaph70\trleft-70\trkeep\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 
\clbrdrr\brdrs\brdrw10 \cltxlrtb \cellx1980\pard\plain \li360\sb100\sa100\nowidctlpar\widctlpar\intbl\adjustright \lang1045\cgrid {\b\fs20 \u8300\'3f }{\fs20 wydruk }{\b\fs20 \cell }\pard \nowidctlpar\widctlpar\intbl\adjustright {\b\fs20 \row 
}\pard\plain \s15\sb240\sa100\nowidctlpar\widctlpar\adjustright \lang1045\cgrid {\b\fs20 FORMA PRZEKAZANIA INFORMACJI:
\par }\pard\plain \li357\sl360\slmult1\nowidctlpar\widctlpar\adjustright \lang1045\cgrid {\b\fs20 \u8300\'3f}{\f20\fs20   Przes\'b3anie informacji poczt\'b9 elektroniczn\'b9}{\fs20  pod adres .................................................... 
\par }\pard\plain \s17\fi-363\li720\sl360\slmult1\nowidctlpar\widctlpar\adjustright \fs20\lang1045\cgrid {\b \u8300\'3f}{\f20   Przes\'b3anie informacji poczt\'b9 pod adres** ...................................................................... \line 
...........................................................................}{...............................................................
\par }\pard\plain \li357\sl360\slmult1\nowidctlpar\widctlpar\adjustright \lang1045\cgrid {\b\fs20 \u8300\'3f}{\f20\fs20   Odbi\'f3r osobi\'9ccie przez wnioskodawc\'ea 
\par }\pard\plain \s17\nowidctlpar\widctlpar\adjustright \fs20\lang1045\cgrid {\f20 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\fi708\li4956\sb100\sa100\nowidctlpar\widctlpar\adjustright \lang1045\cgrid {\fs20 
\par }\pard \s15\fi-4956\li4956\sb100\nowidctlpar\widctlpar\adjustright {\fs20 .....................................................\tab \tab ........................................................
\par }\pard \s15\fi-4248\li4956\sa100\nowidctlpar\widctlpar\adjustright {\f20\fs20 Miejscowo\'9c\'e6, data \tab \tab \tab  podpis wnioskodawcy
\par }\pard \s15\nowidctlpar\widctlpar\adjustright {\fs22 Uwagi:
\par }{\f20\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\sb120\nowidctlpar\widctlpar\adjustright \b\lang1045\cgrid {\f20\fs20 Urz\'b9d zastrzega prawo pobrania op\'b3aty od informacji udost\'eapnionych zgodnie z art. 15 ustawy o dost\'eapie do informacji publicznej
\par }}