REPUBLICA MOLDOVA

MINISTERUL SNTII
SERVICIUL DE SUPRAVEGHERE DE STAT
A SNTII PUBLICE

DOCUMENTAIE MEDICAL
Nr. 319/e

Formular

Aprobat de MS al RM Nr. 828 din 31.10.11

din 05 .02.2010 nr. 79

PROCES-VERBAL
cu privire la contravenie

_______________________________________________

din ____ ________ 20___

locul ncheierii /

Subsemnatul (a) ____________________________________________________________________________

numele, prenumele, patronimicul / ...

n calitate de ________________________________ al _____________________________________________

funcia /

denumirea autoritii pe care o reprezint /

n prezena:

Persoana fizic/persoana cu funcie de rspundere ____________________________________, data naterii

/

numele, prenumele, patronimicul / ...

________________, locul naterii ________________________________________, buletin de identitate seria

nr. _________________, eliberat de oficiul ________ la data de ________, IDNP _____________, domiciliul

_________________________________________________________, locul de munc ____________________

__________________ funcia __________________________________________________________________

n conformitate cu cerinele art. 443 al Codului contravenional al Republicii Moldova, am ntocmit

prezentul proces-verbal
. 443

n timpul supravegherii de stat a sntii publice a _______________________________________________

denumirea, adresa juridic a obiectului verificat, IDNO/

___________________________________________________________________________________________
, ,

___________________________________________________________________________________________
Am constatat, la data de________________, ora ________:

___________________________________________________________________________________________
fapta contravenional, locul i timpul svririi, esena contraveniei / oe , , ,

___________________________________________________________________________________________
______________________________________________________________________________

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
___________________________________________________________________________________
Semntura: ___________

gent constatator

___________
ontravenient

___________
victima (cnd exist)
( )

__________

__________

martor

martor

_____________________________________________________________________________________________
_____________________________________________________________________________

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
prin care se ncalc ____________________________________________________________________________

actul normativ /

ce constituie contravenie, prevzut de art. ________ din Codul Contravenional al Republicii Moldova

Conform prevederilor Codului Contravenional al Republicii Moldova, nclcarea art. _____________ se

, .,

sancioneaz cu amend:

de la ____ pn la _____ u.c. pentru persoana fizic,

.. ,

de la ____ pn la _____ u.c. pentru persoana cu funcie de rspundere,

.. ,

de la ____ pn la _____ u.c. pentru persoana juridic.

o .. .

Drepturile i obligaiile prevzute de art. 34, 378, 384, 387 i 448 a Codului contravenional al Republicii
Moldova, precum i dreptul de a plti jumtate din amend, dac amenda este pltit n cel mult 72 de ore de
la stabilirea ei, i-au fost explicate contravenientului ________________________________________________
semntura /

, . 34, 378, 384 387 448 ,

72
, .

Contravenientul nu este prezent sau refuz s semneze:__________________________________________

_____________________________________________________________________________________
Martorii _____________________________________________________________________________________

numele, prenumele, datele din buletinul de identitate/ ..,

_____________________________________________________________________________________________

_________________________________________________________________________
Obieciile i probele contravenientului i ale victimei (dac exist)__________________________________
( )

_____________________________________________________________________________________________
___________________________________________________________________________________

_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
La procesul-verbal se anexeaz: _________________________________________________________________

_____________________________________________________________________________________________
Examinarea cazului va avea loc la________________________________________________________________

denumirea, adresa juridic a instituiei / ,

data _______________ ora ___________

Semntura

___________

gent constatator

___________
ontravenient

___________
victima (cnd exist)
( )

__________
martor

_________
martor

DECIZIE
innd seama de faptele svrite i apreciind existena de date suficiente pentru constatarea contraveniei
prevzute de art. ___________________ al Codului contravenional al Republicii Moldova,
, . ___________________________

Urmeaz a fi tras la rspundere persoana fizic/persoana juridic/persoana cu funcie de rspundere

//

____________________________________________________________________________________
numele, prenumele, patronimicul /denumirea, datele persoanei fizice care o reprezint / .. / ,

___________________________________________________________________________________________
n calitate de __________________________________________________________________________________________________

_________________________________________________________________________
Data naterii_______________locul naterii ________________________cod fiscal_____________________

Domiciliul/sediul(adresa juridic)______________________________________________________________
/

___________________________________________________________________________________________
Conform prevederilor Codului contravenional al Republicii Moldova, art. ___________________________
a , .

A aplica contravenientului amend n sum de_________________ MDL

Amenda se va achita la Banca _________________________________________________________________

n termen de 30 zile de la comunicare, urmnd ca n acelai termen s se prezinte bonul de plat la CMP
teritorial
30 ,

___________________________________________________________________________________________
localitatea, str., nr./ , ., .

Contestarea procesului-verbal cu privire la contravenie (inclusiv i a Deciziei) se face n instana de

judecat, n termen de 15 zile de la data comunicrii acestuia.
, 15- .

Medic-ef sanitar de stat al ______________________________________ _____________________________

raionul/municipiul / / numele, prenumele/ ...

L..
..

Am primit un exemplar ______________________ data ______________

semntura /