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\pnucrm\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl2\pnucltr\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl3\pndec\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl4\pnlcltr\pnstart1\pnindent720\pnhang{\pntxta )}}{\*\pnseclvl5 \pndec\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl6\pnlcltr\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl7\pnlcrm\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl8\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}\pard\plain \s16\qr \li720\ri0\sb100\sa100\widctlpar\faauto\adjustright\rin0\lin720\itap0 \fs24\lang1045\langfe2052\loch\af0\hich\af0\dbch\af17\cgrid\langnp1045\langfenp2052 {\b \par }\pard \s16\ql \li0\ri0\sb100\sa100\widctlpar\faauto\adjustright\rin0\lin0\itap0 {\hich\af0\dbch\af17\loch\f0 DANE WNIOSKODAWCY \par }{\f40 \hich\af40\dbch\af17\loch\f40 \hich\f40 Nazwisko i Imi\'ea\loch\f40 / Jednostka: ......................... ..................................................... \par }{\lang1031\langfe2052\langnp1031 \hich\af0\dbch\af17\loch\f0 Nr PESEL / REGON:............................................................................................ \par \hich\af0\dbch\af17\loch\f0 Adres: ...................................................................... \par \hich\af0\dbch\af17\loch\f0 Nr telefonu: .......................................................\hich\af0\dbch\af17\loch\f0 ....... \par }\pard \s16\qc \li0\ri-290\sb100\sa100\widctlpar\faauto\adjustright\rin-290\lin0\itap0 {\b \hich\af0\dbch\af17\loch\f0 WNIOSEK \par }\pard \s16\qc \li0\ri0\sb100\sa100\widctlpar\faauto\adjustright\rin0\lin0\itap0 {\b\f40 \hich\af40\dbch\af17\loch\f40 \hich\f40 O UDOST\'ca\loch\f40 PNIENIE INFORMACJI PUBLICZNEJ \par }\pard \s16\ql \li0\ri-650\sb100\sa100\widctlpar\faauto\adjustright\rin-650\lin0\itap0 {\f40 \hich\af40\dbch\af17\loch\f40 \hich\f40 Na podstawie art. 2 ust. 1 ustawy o dost\'ea\loch\f40 \hich\f40 pie do informacji publicznej z dnia 6 wrze\'9c\loch\f40 \hich\f40 nia 2001 r. (Dz. U. Nr 112, poz. 1198) zwracam si\'ea\loch\f40 \hich\f40 z pro\'9c\loch\f40 \hich\f40 b\'b9\loch\f40 \hich\f40 o udost\'ea\loch\f40 \hich\f40 pnienie informacji w nast\'ea\loch\f40 \hich\f40 puj\'b9\loch\f40 cym zakresie: \par }{\hich\af0\dbch\af17\loch\f0 ......\hich\af0\dbch\af17\loch\f0 ............................................................................................................................................................ \par \hich\af0\dbch\af17\loch\f0 ...................................................................................................\hich\af0\dbch\af17\loch\f0 ............................................................... \par \hich\af0\dbch\af17\loch\f0 .................................................................................................................................................................. \par \hich\af0\dbch\af17\loch\f0 .............................\hich\af0\dbch\af17\loch\f0 ..................................................................................................................................... \par \hich\af0\dbch\af17\loch\f0 ..........................................................................................................................\hich\af0\dbch\af17\loch\f0 ........................................ \par }\pard \s16\ql \li0\ri0\sb100\sa100\widctlpar\faauto\adjustright\rin0\lin0\itap0 {\b\f40 \hich\af40\dbch\af17\loch\f40 \hich\f40 SPOS\'d3\loch\f40 \hich\f40 B I FORMA UDOST\'ca\loch\f40 PNIENIA 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 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\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 \s16\ql \li0\ri0\sb100\sa100\widctlpar\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1045\langfe2052\loch\af0\hich\af0\dbch\af17\cgrid\langnp1045\langfenp2052 {\b\f40 \hich\af40\dbch\af17\loch\f40 \hich\f40 RODZAJ NO\'8c\loch\f40 NIKA: \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\faauto\adjustright\rin0\lin360 \fs24\lang1045\langfe2052\loch\af0\hich\af0\dbch\af17\cgrid\langnp1045\langfenp2052 {\b \loch\af0\dbch\af17\hich\f0 \u1649\'3f\hich\af0\dbch\af17\loch\f0 }{ \hich\af0\dbch\af17\loch\f0 dyskietka 3,5 }{\b \cell \loch\af0\dbch\af17\hich\f0 \u1649\'3f\hich\af0\dbch\af17\loch\f0 }{\hich\af0\dbch\af17\loch\f0 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 \s16\ql \li0\ri0\sb240\sa100\widctlpar\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1045\langfe2052\loch\af0\hich\af0\dbch\af17\cgrid\langnp1045\langfenp2052 {\b \hich\af0\dbch\af17\loch\f0 FORMA PRZEKAZANIA INFORMACJI: \par }\pard\plain \ql \li357\ri0\sl360\slmult1\widctlpar\faauto\adjustright\rin0\lin357\itap0 \fs24\lang1045\langfe2052\loch\af0\hich\af0\dbch\af17\cgrid\langnp1045\langfenp2052 {\b \loch\af0\dbch\af17\hich\f0 \u1649\'3f}{\f40 \hich\af40\dbch\af17\loch\f40 \hich\f40 Przes\'b3\hich\af40\dbch\af17\loch\f40 \hich\f40 anie informacji poczt\'b9\loch\f40 \hich\f40 elektroniczn\'b9\loch\f40 pod adres .................................................... \par }\pard\plain \s18\ql \fi-363\li720\ri0\sl360\slmult1\widctlpar\faauto\adjustright\rin0\lin720\itap0 \fs20\lang1045\langfe2052\loch\af0\hich\af0\dbch\af17\cgrid\langnp1045\langfenp2052 {\b\fs24 \loch\af0\dbch\af17\hich\f0 \u1649\'3f}{\f40\fs24 \hich\af40\dbch\af17\loch\f40 \hich\f40 Przes\'b3\loch\f40 \hich\f40 anie informacji poczt\'b9\loch\f40 pod adres** ...................................................................... \line ......................................}{\fs24 \hich\af0\dbch\af17\loch\f0 .................................................................................................... \par }\pard\plain \ql \li357\ri0\sl360\slmult1\widctlpar\faauto\adjustright\rin0\lin357\itap0 \fs24\lang1045\langfe2052\loch\af0\hich\af0\dbch\af17\cgrid\langnp1045\langfenp2052 {\b \loch\af0\dbch\af17\hich\f0 \u1649\'3f}{\f40 \hich\af40\dbch\af17\loch\f40 \hich\f40 Odbi\'f3\loch\f40 \hich\f40 r osobi\'9c\loch\f40 \hich\f40 cie przez wnioskodawc\'ea\loch\f40 \par }\pard\plain \s18\ql \li0\ri0\widctlpar\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1045\langfe2052\loch\af0\hich\af0\dbch\af17\cgrid\langnp1045\langfenp2052 {\f40 \hich\af40\dbch\af17\loch\f40 \hich\f40 Wyra\'bf\loch\f40 \hich\f40 am zgod\'ea\loch\f40 \hich\f40 na przetwarzanie moich danych osobowych zgodnie z ustaw\'b9\loch\f40 o ochronie danych osobowych z dnia 29.08.19\hich\af40\dbch\af17\loch\f40 \hich\f40 97 r. (Dz.U. .Nr 133 poz 883.z p\'f3\'9f\loch\f40 n. zm.) \par }\pard\plain \s16\ql \fi708\li4956\ri0\sb100\sa100\widctlpar\faauto\adjustright\rin0\lin4956\itap0 \fs24\lang1045\langfe2052\loch\af0\hich\af0\dbch\af17\cgrid\langnp1045\langfenp2052 { \par }\pard \s16\ql \fi-4956\li4956\ri0\sb100\widctlpar\faauto\adjustright\rin0\lin4956\itap0 {\hich\af0\dbch\af17\loch\f0 .....................................................\tab \tab ........................................................ \par }\pard \s16\ql \fi-4248\li4956\ri0\sa100\widctlpar\faauto\adjustright\rin0\lin4956\itap0 {\f40 \hich\af40\dbch\af17\loch\f40 \hich\f40 Miejscowo\'9c\'e6\loch\f40 , data \tab \tab \tab podpis wnioskodawcy \par }\pard \s16\ql \li0\ri0\widctlpar\faauto\adjustright\rin0\lin0\itap0 {\fs22 \hich\af0\dbch\af17\loch\f0 Uwagi: \par }{\f40\fs22 \hich\af40\dbch\af17\loch\f40 \hich\f40 * prosz\'ea\loch\f40 \hich\f40 zakre\'9c\loch\f40 \hich\f40 li\'e6\loch\f40 \hich\f40 w\'b3\loch\f40 \hich\f40 a\'9c\loch\f40 \hich\f40 ciwe pole krzy\'bf\loch\f40 ykiem \par }{\fs22 \hich\af0\dbch\af17\loch\f0 ** wype}{\f40\fs22 \loch\af40\dbch\af17\hich\f40 \'b3\loch\f40 \hich\f40 ni\'e6\loch\f40 \hich\f40 je\'9c\loch\f40 \hich\f40 li adres jest inny ni\'bf\loch\f40 \hich\f40 podany wcze\'9c\loch\f40 niej \par }\pard\plain \s17\ql \li0\ri0\sb120\widctlpar\faauto\adjustright\rin0\lin0\itap0 \b\fs24\lang1045\langfe2052\loch\af0\hich\af0\dbch\af17\cgrid\langnp1045\langfenp2052 {\f40 \hich\af40\dbch\af17\loch\f40 \hich\f40 Urz\'b9\loch\f40 \hich\f40 d zastrzega prawo pobrania op\'b3\loch\f40 \hich\f40 aty od informacji udost\'ea\loch\f40 \hich\f40 pnionych zgodnie z art. 15 ustawy o dost\'ea\loch\f40 pie do informacji publicznej \par }\pard\plain \ql \li0\ri0\widctlpar\faauto\adjustright\rin0\lin0\itap0 \fs24\lang1045\langfe2052\loch\af0\hich\af0\dbch\af17\cgrid\langnp1045\langfenp2052 { \par }}