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Application for participation in the «Orley» project

.                                                                                                         Form

 

                             Application

    for participation in the «Orley» project

                             To department of employment and social programs

                ______________________________________________

                                           (settlement, oblast)

from ________________________________________________________

                       (Full name (in case of its availability) the applicant)

living at ______________________________

                                                           (settlement, oblast) _________________________________________________________

                        (street, No. of the house and apartment, phone) document

identity certificate and (or) passport No. _______ ________________________________________________________

date of issue _________________________________

individual identification number ____________________________________________

Bank details:

bank name __________________________

bank account No. ___________________________

No. of a personal account _____________________________

Statement

      I ask to accept me (my family) to the «Orley» project and to provide the caused monetary help on the basis of the social contract of activation of a family.

      I consent to using the information on members of my family (including me) (the income, education, the residence, marital status) for assessment of competency of participation in the project, and also checking and updating the relevant information in public authorities.

      I am informed that information provided by me is confidential and will be used only for implementation of social programs.

     My family (including me) consists from _____ persons.

     In case of changes of the data provided by me I promise to report on it within fifteen working days.

I am warned about responsibility for granting false information and doubtful (counterfeit) documents.

     At the same time I ask to consider the possibility of granting according to the legislation of the Republic of Kazakhstan to me and terms of my family:

  • special social services;
  • rehabilitation measures for disabled people (equipment for visually and audibly challenged people, prosthetic and orthopedic tools, tools for movement, social services of the individual assistant, expert in sign language);

- social help according to the decision of local representative bodies.  

   «____»__________20__ year  __________________

            (date)                                  (signature of applicant)

 

    For office marks of department of employment and social programs.______________________________________________________________________________

______________________________________________________________________________

     Documents accepted

«____»__________20__ year

      _____________________________________________________________________________

((Full name and signature of the receiving person)

     
  _________   Family (applicant’s) registration number

 

    The statement with the enclosed documents is transferred to local Comission
     «__»__________ 20__ year
     Accepted «__»________ 20__ year
     ___________________________ Full name and signature of the member of local Comission, who has accepted the documents     Applicant signature _______________

     Mark of the authoritative body on receipt of documents from the village akim «__»_________ 20__ year,                                              

(Full name and signature of the receiving person)

_____________________________________________________________________
 

 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 

(cut)
 

    I am warned about responsibility for granting false information and

doubtful (counterfeit) documents.

     The petition from citizen _________________________ with the enclosed documents (number), with registration number of family ________

     accepted «____» _____________20__ year

    (Full name and signature of the receiving person) ____________________________________

______________________________________________________________________________

 

 

Changed on 15 August, 2016 - 19:38
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