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310 Socbdt6 des Nations - Recueil des Traitds. 1931 MODELUL Nr. i WZdR Nr. I LA ARTICOLUL 4 AL CONVENTIUNEI do artykulu 4 Konwencji TRAFICUL DE FRONTIERA LOCAL ROMANO-POLON polsko-rumuiski ruch pograniczny Certificat de trecere valabil o singura dater Nr ................... Przepustka jednorazowa Nr ................ N um ele §i pronum ele .................................................................... Nazwisko i imiC O cupatiunea ............................................................................ Zaw6d Locul na~terei ............................... data na~terei ............................. Mitisce urodzenia data urodzenia N ationalitatea ......................................................................... Obywatelstwo D om iciliat in com una .................................................................. Miejsce zamieszkania Scopul trecerei peste frontierd ........................................................... Pow6d przekroczenia granicy Punctul de trecere peste frontier ....................................................... Miejsce przekroczenia granicy Valabil pentru a m erge in comuna ....................................................... Wa~na na pobyt w gminie V alabil p An d la ........................................................................ Wa~na do ........................................................................... RECTO Verte No 2752
1931 League of Nations - Treaty Series. 311 Locul fotografiei. Miejsce na !otograifk. VERSO In lipsa fotografiei, titularul permisului de fata va posedh o alta carte de identitate liberaa sau eventual certificatii oficial §i insotit5. de o fotografie. Posiadacz ninieiszej przepustki ma inny dow6d tosamogci urzodowy wydany albo potwierdzony i zaopatrzony w /otogra/jC Semnatura titularului, Wlasnorczny podpis posiadacza, Stampila oficiald. PieczC6 urz~dowa. Numele persoanelor minore, mai mici de 15 ani, §i care insotesc pe titularul certificatului Wymienienie os6b maloletnich w wieku poniiej 15 lat, towarzyszqcych posiadaczowi przepustki Localitatea in care a fost liberat permisul ........................ data ............... Miejsce wystawienia przepustki data A utoritatea .............................................. Urzqd Semndtura, No. 2752 Podpis, Stampila oficial. Pieczq urzedowa
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SOCIIT8 DES NATIONS Recueil des Tra
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