Sample application form

Head of
Kirovohrad regional
state administration
CHORNA MARIA VOLODYMYRIVNI
Last name, first name, patronymic of the applicant
Place of residence

STATEMENT

(suggestion, complaint)

1. The essence of the issue, comments, suggestions, statements or complaints, requests or demands.

I do not object to the use of the personal data provided in the consideration of the issue.

Date

Signature