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<b style="mso-bidi-font-weight:normal"><i style="mso-bidi-font-style:normal">İŞLETİCİ KİMLİK BİLDİRME BELGESİ</span>[/i][/b]
İŞLETİCİ KİMLİK
BİLDİRME BELGESİ (FORM-1)
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<t><tr style="mso-yfti-irow:0;mso-yfti-firstrow:yes;height:26.05pt">
<td style="width:98.5pt;border:solid text 1.0pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:26.05pt" valign="top" width="131">
İş Yerinin Adı
</td>
<td colspan="3" style="width:144.8pt;border:solid text 1.0pt; border-left:none;mso-border-left-alt:solid text .5pt;mso-border-alt: solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:26.05pt" valign="top" width="193">
</td>
<td colspan="2" style="width:72.8pt;border:solid text 1.0pt; border-left:none;mso-border-left-alt:solid text .5pt;mso-border-alt: solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:26.05pt" valign="top" width="97">
Türü
</td>
<td colspan="6" style="width:108.3pt;border:solid text 1.0pt; border-left:none;mso-border-left-alt:solid text .5pt;mso-border-alt: solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:26.05pt" valign="top" width="144">
</td>
<td colspan="3" rowspan="5" style="width:101.55pt;border:solid text 1.0pt; border-left:none;mso-border-left-alt:solid text .5pt;mso-border-alt: solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:26.05pt" width="135">
FOTOĞRAF</span>
</td>
</tr>
<tr style="mso-yfti-irow:1;height:24.65pt">
<td rowspan="4" style="width:98.5pt;border:solid text 1.0pt; border-top:none;mso-border-top-alt:solid text .5pt;mso-border-alt:solid text .5pt; padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" width="131">
Adresi</span>
</td>
<td style="width:72.35pt;border-top:none;border-left: none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="96">
İli
</td>
<td colspan="2" style="width:72.45pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="97">
İlçe
</td>
<td colspan="2" style="width:72.8pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="97">
Mah/köy
</td>
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Mevki- semt
</td>
</tr>
<tr style="mso-yfti-irow:2;height:24.65pt">
<td style="width:72.35pt;border-top:none;border-left: none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="96">
AMASYA
</td>
<td colspan="2" style="width:72.45pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="97">
MERKEZ
</td>
<td colspan="2" style="width:72.8pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="97">
</td>
<td colspan="6" style="width:108.3pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="144">
------------------
</td>
</tr>
<tr style="mso-yfti-irow:3;height:24.65pt">
<td colspan="3" style="width:144.8pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="193">
Cadde- Sokak
</td>
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Bina no
</td>
<td colspan="6" style="width:108.3pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="144">
Telefon No
</td>
</tr>
<tr style="mso-yfti-irow:4;height:24.65pt">
<td colspan="3" style="width:144.8pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="193">
</td>
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</td>
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</td>
</tr>
<tr style="mso-yfti-irow:5;height:24.65pt">
<td colspan="15" style="width:525.95pt;border:solid text 1.0pt; border-top:none;mso-border-top-alt:solid text .5pt;mso-border-alt:solid text .5pt; padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="701">
TESİSİN SORUMLU İŞLETİCİNİN</span>
</td>
</tr>
<tr style="mso-yfti-irow:6;height:24.65pt">
<td style="width:98.5pt;border:solid text 1.0pt; border-top:none;mso-border-top-alt:solid text .5pt;mso-border-alt:solid text .5pt; padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="131">
T.C Kimlik No
</td>
<td colspan="2" style="width:117.5pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="157">
</td>
<td colspan="4" rowspan="2" style="width:108.0pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" width="144">
NÜFUSA KAYITLI OLDUĞU</span>
</td>
<td colspan="4" style="width:81.0pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="108">
İl
</td>
<td colspan="3" style="width:64.15pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="86">
İlçe
</td>
<td style="width:56.8pt;border-top:none;border-left:none; border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="76">
Mah/Köy
</td>
</tr>
<tr style="mso-yfti-irow:7;height:24.65pt">
<td style="width:98.5pt;border:solid text 1.0pt; border-top:none;mso-border-top-alt:solid text .5pt;mso-border-alt:solid text .5pt; padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="131">
Soyadı Adı
</td>
<td colspan="2" style="width:117.5pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="157">
</td>
<td colspan="4" style="width:81.0pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="108">
</td>
<td colspan="3" style="width:64.15pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="86">
</td>
<td style="width:56.8pt;border-top:none;border-left:none; border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="76">
</td>
</tr>
<tr style="mso-yfti-irow:8;height:24.65pt">
<td style="width:98.5pt;border:solid text 1.0pt; border-top:none;mso-border-top-alt:solid text .5pt;mso-border-alt:solid text .5pt; padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="131">
Baba –Ana Adı
</td>
<td colspan="2" style="width:117.5pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="157">
</td>
<td colspan="4" style="width:108.0pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="144">
Pasaport Tarih ve Sayısı
</td>
<td colspan="8" style="width:201.95pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="269">
---------------------
</td>
</tr>
<tr style="mso-yfti-irow:9;height:24.65pt">
<td style="width:98.5pt;border:solid text 1.0pt; border-top:none;mso-border-top-alt:solid text .5pt;mso-border-alt:solid text .5pt; padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="131">
Doğum Yeri ve Tarihi
</td>
<td colspan="2" style="width:117.5pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="157">
</td>
<td colspan="4" style="width:108.0pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="144">
İkamet Tez. Tarih ve Sayısı
</td>
<td colspan="8" style="width:201.95pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="269">
--------------------
</td>
</tr>
<tr style="mso-yfti-irow:10;height:24.65pt">
<td style="width:98.5pt;border:solid text 1.0pt; border-top:none;mso-border-top-alt:solid text .5pt;mso-border-alt:solid text .5pt; padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="131">
Uyruğu
</td>
<td colspan="2" style="width:117.5pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="157">
</td>
<td colspan="4" style="width:108.0pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="144">
İşe Başlama Tarihi
</td>
<td colspan="8" style="width:201.95pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="269">
</td>
</tr>
<tr style="mso-yfti-irow:11;height:24.65pt">
<td style="width:98.5pt;border:solid text 1.0pt; border-top:none;mso-border-top-alt:solid text .5pt;mso-border-alt:solid text .5pt; padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="131">
Ev Adresi ve Telefonu
</td>
<td colspan="2" style="width:117.5pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="157">
</td>
<td colspan="4" style="width:108.0pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="144">
İmzası
</td>
<td colspan="8" style="width:201.95pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="269">
</td>
</tr>
<tr style="mso-yfti-irow:12;height:24.65pt">
<td colspan="15" style="width:525.95pt;border:solid text 1.0pt; border-top:none;mso-border-top-alt:solid text .5pt;mso-border-alt:solid text .5pt; padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="701">
ÖNCEKİ SORUMLU İŞLETMECİNİN</span>
</td>
</tr>
<tr style="mso-yfti-irow:13;height:24.65pt">
<td style="width:98.5pt;border:solid text 1.0pt; border-top:none;mso-border-top-alt:solid text .5pt;mso-border-alt:solid text .5pt; padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="131">
Soyadı ve Adı
</td>
<td colspan="3" style="width:144.8pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="193">
</td>
<td colspan="5" style="width:132.5pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="177">
Ayrılış Tarihi
</td>
<td colspan="6" style="width:150.15pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="200">
</td>
</tr>
<tr style="mso-yfti-irow:14;height:24.65pt">
<td colspan="15" style="width:525.95pt;border:solid text 1.0pt; border-top:none;mso-border-top-alt:solid text .5pt;mso-border-alt:solid text .5pt; padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="701">
TESİSİN, KANUNİ TEMSİLCİSİ, KİRACISI VEYA AMİRİNİN</span>
</td>
</tr>
<tr style="mso-yfti-irow:15;height:26.05pt">
<td style="width:98.5pt;border:solid text 1.0pt; border-top:none;mso-border-top-alt:solid text .5pt;mso-border-alt:solid text .5pt; padding:0cm 5.4pt 0cm 5.4pt;height:26.05pt" valign="top" width="131">
T.C Kimlik No
</td>
<td colspan="2" style="width:117.5pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:26.05pt" valign="top" width="157">
</td>
<td colspan="4" rowspan="2" style="width:108.0pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:26.05pt" width="144">
NÜFUSA KAYITLI OLDUĞU</span>
</td>
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İl
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İlçe
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Mah/Köy
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Soyadı Adı
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</td>
<td colspan="4" style="width:81.0pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="108">
</td>
<td colspan="3" style="width:64.15pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="86">
</td>
<td style="width:56.8pt;border-top:none;border-left:none; border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="76">
</td>
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<tr style="mso-yfti-irow:17;height:24.65pt">
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Baba –Ana Adı
</td>
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</td>
<td colspan="4" style="width:108.0pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="144">
Pasaport Tarih ve Sayısı
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</td>
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Doğum Yeri ve Tarihi
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</td>
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İkamet Tez. Tarih ve Sayısı
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</td>
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Uyruğu
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</td>
<td colspan="12" style="width:309.95pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="413">
DURUMU
</td>
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<tr style="mso-yfti-irow:20;height:24.65pt">
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EV Adresi ve
Telefonu
</td>
<td colspan="2" rowspan="2" style="width:117.5pt;border-top: none;border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="157">
</td>
<td colspan="2" style="width:90.0pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="120">
Sahip
</td>
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K.Temsilci
</td>
<td colspan="3" style="width:63.0pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="84">
Kiracı
</td>
<td colspan="2" style="width:84.95pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="113">
Amir
</td>
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<tr style="mso-yfti-irow:21;height:24.65pt">
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</td>
<td colspan="5" style="width:72.0pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="96">
</td>
<td colspan="3" style="width:63.0pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="84">
</td>
<td colspan="2" style="width:84.95pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="113">
</td>
</tr>
<tr style="mso-yfti-irow:22;height:24.65pt">
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Yukarıdaki
Bilgilerin Doğruluğunu onaylarım……/…../20….
</span>İmzası:
</td>
</tr>
<tr style="mso-yfti-irow:23;height:24.65pt">
<td colspan="15" style="width:525.95pt;border:solid text 1.0pt; border-top:none;mso-border-top-alt:solid text .5pt;mso-border-alt:solid text .5pt; padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="701">
Teslim Alanın
</td>
</tr>
<tr style="mso-yfti-irow:24;height:24.65pt">
<td style="width:98.5pt;border:solid text 1.0pt; border-top:none;mso-border-top-alt:solid text .5pt;mso-border-alt:solid text .5pt; padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="131">
Adı Soyadı
</td>
<td colspan="3" style="width:144.8pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="193">
</td>
<td colspan="4" style="width:98.7pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="132">
Alınış Tarihi
</td>
<td colspan="7" style="width:183.95pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:24.65pt" valign="top" width="245">
</td>
</tr>
<tr style="mso-yfti-irow:25;height:26.05pt">
<td style="width:98.5pt;border:solid text 1.0pt; border-top:none;mso-border-top-alt:solid text .5pt;mso-border-alt:solid text .5pt; padding:0cm 5.4pt 0cm 5.4pt;height:26.05pt" valign="top" width="131">
Rütbesi
</td>
<td colspan="3" style="width:144.8pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:26.05pt" valign="top" width="193">
</td>
<td colspan="4" style="width:98.7pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:26.05pt" valign="top" width="132">
İmzası
</td>
<td colspan="7" style="width:183.95pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:26.05pt" valign="top" width="245">
</td>
</tr>
<tr style="mso-yfti-irow:26;mso-yfti-lastrow:yes;height:26.05pt">
<td style="width:98.5pt;border:solid text 1.0pt; border-top:none;mso-border-top-alt:solid text .5pt;mso-border-alt:solid text .5pt; padding:0cm 5.4pt 0cm 5.4pt;height:26.05pt" valign="top" width="131">
Görevi
</td>
<td colspan="3" style="width:144.8pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:26.05pt" valign="top" width="193">
</td>
<td colspan="11" style="width:282.65pt;border-top:none; border-left:none;border-bottom:solid text 1.0pt;border-right:solid text 1.0pt; mso-border-top-alt:solid text .5pt;mso-border-left-alt:solid text .5pt; mso-border-alt:solid text .5pt;padding:0cm 5.4pt 0cm 5.4pt;height:26.05pt" valign="top" width="377">
</td>
</tr>
<tr height="0">
<td style="border:none" width="131">
</td>
<td style="border:none" width="96">
</td>
<td style="border:none" width="60">
</td>
<td style="border:none" width="36">
</td>
<td style="border:none" width="84">
</td>
<td style="border:none" width="13">
</td>
<td style="border:none" width="11">
</td>
<td style="border:none" width="24">
</td>
<td style="border:none" width="45">
</td>
<td style="border:none" width="3">
</td>
<td style="border:none" width="36">
</td>
<td style="border:none" width="26">
</td>
<td style="border:none" width="22">
</td>
<td style="border:none" width="38">
</td>
<td style="border:none" width="76">
</td>
</tr>
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