Указ Губернатора Орловской области от 30.10.2012 № 441

деятельности, прилагаю.
     Достоверность представленных документов подтверждаю.

__________________________________________________________________
  (Ф.И.О. руководителя постоянно действующего исполнительного органа
юридического лица или иного лица, имеющего право действовать от имени
   этого юридического лица/Ф.И.О. индивидуального предпринимателя)
     
 "_____" ______________ 20___ г. ______________________
                              (Подпись)
                                 М.П.



                                                          Приложение 3
                                                   к административному
                                             регламенту предоставления
                                         Департаментом здравоохранения
                              и социального развития Орловской области
                              государственной услуги по лицензированию
                         фармацевтической деятельности (за исключением
                            деятельности, осуществляемой организациями
                          оптовой торговли лекарственными средствами и
                            аптечными организациями, подведомственными
                                    федеральным органам исполнительной
                                               власти, государственным
                                                       академиям наук)




                                                         В Департамент
                                                     здравоохранения и
                                                  социального развития
                                                     Орловской области

Регистрационный номер: __________________________ от________________
 (заполняется лицензирующим органом)

 
                              Заявление
       (для юридического лица/индивидуального предпринимателя)

     о переоформлении лицензии на осуществление фармацевтической
                             деятельности

Регистрационный N_______________________________________________
лицензии от "____"_______________20___г., предоставленной ____________
___________________________________________________________________
                 (наименование лицензирующего органа)

I. В связи:
__*с реорганизацией юридического лица в форме преобразования;
__* реорганизацией юридического лица в форме слияния;
__* изменением наименования юридического лица;
__* изменением реквизитов  документа индивидуального  предпринимателя,
удостоверяющего его личность;
__* изменением адреса места нахождения юридического лица;


__* изменение  реквизитов документа  индивидуального  предпринимателя,
удостоверяющего его личность;
__* изменением   адреса   места   осуществления   юридическим    лицом
лицензируемого  вида  деятельности  при  фактически  неизменном  месте
осуществления деятельности.
* Нужное указать
     

|——————|—————————————————————————|——————————————————————————————————————|———————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  N   |  Сведения о заявителе   |  Сведения о лицензиате/ лицензиатах  |                                          Новые сведения о лицензиате или его правопреемнике                                           |
|——————|—————————————————————————|——————————————————————————————————————|———————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  1   |            2            |                  3                   |                                                                   4                                                                   |
|——————|—————————————————————————|——————————————————————————————————————|———————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  1.  | Организационно-правовая |                                      |                                                                                                                                       |
|      | форма и полное          |                                      |                                                                                                                                       |
|      | наименование            |                                      |                                                                                                                                       |
|      | юридического лица       |                                      |                                                                                                                                       |
|      |                         |                                      |                                                                                                                                       |
|——————|—————————————————————————|——————————————————————————————————————|———————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  2.  | Сокращенное             |                                      |                                                                                                                                       |
|      | наименование            |                                      |                                                                                                                                       |
|      | юридического лица (в    |                                      |                                                                                                                                       |
|      | случае, если имеется)   |                                      |                                                                                                                                       |
|      |                         |                                      |                                                                                                                                       |
|——————|—————————————————————————|——————————————————————————————————————|———————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  3.  | Фирменное наименование  |                                      |                                                                                                                                       |
|      | юридического лица (в    |                                      |                                                                                                                                       |
|      | случае, если имеется)   |                                      |                                                                                                                                       |
|      |                         |                                      |                                                                                                                                       |
|——————|—————————————————————————|——————————————————————————————————————|———————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  4.  | Адрес местонахождения   |                                      |                                                                                                                                       |
|      | юридического лица       |                                      |                                                                                                                                       |
|      |                         |                                      |                                                                                                                                       |
|——————|—————————————————————————|——————————————————————————————————————|———————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  5.  | Государственный         |                                      |                                                                                                                                       |
|      | регистрационный номер   |                                      |                                                                                                                                       |
|      | записи о создании       |                                      |                                                                                                                                       |
|      | юридического лица       |                                      |                                                                                                                                       |
|——————|—————————————————————————|——————————————————————————————————————|———————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  1   |            2            |                  3                   |                                                                   4                                                                   |
|——————|—————————————————————————|——————————————————————————————————————|———————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  6.  | Данные документа,       | Выдан __________________             |      Выдан ______________________                                                                                                     |
|      | подтверждающего факт    |      (орган, выдавший документ)      |                                                      (орган, выдавший документ)                                                       |
|      | внесения сведений о     |                                      |                                                                                                                                       |
|      | юридическом лице в      | Дата выдачи __________________       |                                                                                                                                       |
|      | Единый государственный  | Бланк:                               |      Дата выдачи ______________________                                                                                               |
|      | реестр юридических лиц, | серия ____________                   |      Бланк:                                                                                                                           |
|      | с указанием адреса      | N _______________                    |      серия _______________                                                                                                            |
|      | местонахождения органа, |                                      |      N __________________                                                                                                             |
|      | осуществившего          | Адрес_____________                   |                                                                                                                                       |
|      | государственную         |                                      |      Адрес_________________                                                                                                           |
|      | регистрацию             |                                      |                                                                                                                                       |
|——————|—————————————————————————|——————————————————————————————————————|———————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  7.  | Данные документа,       | Выдан __________________________________________                                                                                                                             |
|      | подтверждающего факт    |  (орган, выдавший документ)                                                                                                                                                  |
|      | внесения                |                                                                                                                                                                              |
|      | соответствующих         | Дата выдачи ___________________________________________                                                                                                                      |
|      | изменений в Единый      |                                                                                                                                                                              |
|      | государственный реестр  | Бланк: серия __________ N __________________                                                                                                                                 |
|      | юридических лиц.        |                                                                                                                                                                              |
|      |                         | Адрес_____________________________________                                                                                                                                   |
|      | Наименование, код       | ________________________________________________________________________________________________________________________                                                     |
|      | подразделения,          | Код подразделения: ______________________________________                                                                                                                    |
|      | адрес налоговой         | Адрес налоговой инспекции: ______________________________________                                                                                                            |
|      | инспекции               |                                                                                                                                                                              |
|      | (с указанием почтового  |                                                                                                                                                                              |
|      | индекса)                |                                                                                                                                                                              |
|——————|—————————————————————————|——————————————————————————————————————|———————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  8.  | Идентификационный номер |                                      |                                                                                                                                       |
|      | налогоплательщика       |                                      |                                                                                                                                       |
|      |                         |                                      |                                                                                                                                       |
|      |                         |                                      |                                                                                                                                       |
|——————|—————————————————————————|——————————————————————————————————————|———————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  9.  | Данные документа о      | Выдан __________________             | Выдан ______________________                                                                                                          |
|      | постановке лицензиата   |      (орган, выдавший документ)      |                                                       (орган, выдавший документ)                                                      |
|      | (юридического лица) на  |                                      |                                                                                                                                       |
|      | учет в налоговом органе |                                      |                                                                                                                                       |
|——————|—————————————————————————|——————————————————————————————————————|———————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  1   |            2            |                  3                   |                                                                   4                                                                   |
|——————|—————————————————————————|——————————————————————————————————————|———————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|      |                         | Дата выдачи __________________       | Дата выдачи ______________________                                                                                                    |
|      |                         |                                      |                                                                                                                                       |
|      |                         | Бланк:                               | Бланк:                                                                                                                                |
|      |                         | серия ____________                   | серия ____________                                                                                                                    |
|      |                         | N _______________                    | N _______________                                                                                                                     |
|      |                         | Адрес_______________________________ | Адрес_______________________________                                                                                                  |
|      |                         |                                      |                                                                                                                                       |
|——————|—————————————————————————|——————————————————————————————————————|———————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 10.  | Сведения о              |                                                                                                                                                                              |
|      | распорядительном        | ___________________________________________                                                                                                                                  |
|      | документе, на основании |                                                                          (орган, принявший решение)                                                                          |
|      | которого произошло      |                                                                                                                                                                              |
|      | изменение адреса места  | Реквизиты документа                                                                                                                                                          |
|      | осуществления           | ____________________________________________________________________________________________________________________________________________________________________________ |
|      | деятельности            |                                                                                                                                                                              |
|      |                         |                                                                                                                                                                              |
|——————|—————————————————————————|——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 11.  | Реквизиты документа,    | N платежного                                                                                                                                                                 |
|      | подтверждающего факт    | поручения __________________                                                                                                                                                 |
|      | уплаты государственной  | Дата ______________                                                                                                                                                          |
|      | пошлины за              | В размере __________                                                                                                                                                         |
|      | предоставление          |                                                                                                                                                                              |
|      | лицензии, либо иные     |                                                                                                                                                                              |
|      | сведения,               |                                                                                                                                                                              |
|      | подтверждающие факт     |                                                                                                                                                                              |
|      | уплаты указанной        |                                                                                                                                                                              |
|      | государственной пошлины |                                                                                                                                                                              |
|——————|—————————————————————————|————————————————————————|—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 12.  | Адрес(а) мест           |                        | 2. Аптечные организации:                                                                                                                            |
|      | осуществления           |                        |                                                                                                                                                     |
|      | лицензируемого вида     |                        | 2.1. Аптека готовых лекарственных форм                                                                                                              |
|      | деятельности.           |                        | ________________________                                                                                                                            |
|      |                         |                        |                                              (адрес места осуществления фармацевтической деятельности)                                              |
|      | Выполняемые работы,     |                        |                                                                                                                                                     |
|      | оказываемые услуги,     |                        |                                                                                                                                                     |
|      | составляющие            |                        |                                                                                                                                                     |
|——————|—————————————————————————|————————————————————————|—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  1   |            2            |           3            |                                                                          4                                                                          |
|——————|—————————————————————————|————————————————————————|—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|      | фармацевтическую        |                        | 2.2. Аптека производственная                                                                                                                        |
|      | деятельность в сфере    |                        | ________________________                                                                                                                            |
|      | обращения лекарственных |                        | (адрес места осуществления фармацевтической деятельности)                                                                                           |
|      | средств для             |                        |                                                                                                                                                     |
|      | медицинского применения |                        | 2.3. Аптека производственная с правом изготовления асептических лекарственных препаратов                                                            |
|      |                         |                        | ________________________                                                                                                                            |
|      |                         |                        | (адрес места осуществления фармацевтической деятельности)                                                                                           |
|      |                         |                        |                                                                                                                                                     |
|      |                         |                        | 2.4. Аптечный пункт                                                                                                                                 |
|      |                         |                        | ________________________ (адрес места осуществления лицензируемого вида деятельности)                                                               |
|      |                         |                        |                                                                                                                                                     |
|      |                         |                        | 2.5. Аптечный киоск                                                                                                                                 |
|      |                         |                        | ________________________                                                                                                                            |
|      |                         |                        | (адрес места осуществления лицензируемого вида деятельности)                                                                                        |
|      |                         |                        | __* хранение лекарственных средств для медицинского применения;                                                                                     |
|      |                         |                        | __* хранение лекарственных препаратов для медицинского применения;                                                                                  |
|      |                         |                        | __* перевозка лекарственных препаратов для медицинского применения;                                                                                 |
|      |                         |                        | __* перевозка лекарственных средств для медицинского применения;                                                                                    |
|      |                         |                        | __* розничная торговля лекарственными препаратами для медицинского применения;                                                                      |
|      |                         |                        | __* отпуск лекарственных препаратов для медицинского применения.                                                                                    |
|      |                         |                        |                                                                                                                                                     |
|      |                         |                        |                                                                                                                                                     |
|——————|—————————————————————————|————————————————————————|—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  1   |            2            |           3            |                                                                          4                                                                          |
|——————|—————————————————————————|————————————————————————|—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|      |                         |                        | 3. Структурные подразделения медицинских организаций:                                                                                               |
|      |                         |                        |                                                                                                                                                     |
|      |                         |                        | 3.1. Аптека готовых лекарственных форм                                                                                                              |
|      |                         |                        | ________________________                                                                                                                            |
|      |                         |                        | (адрес места осуществления фармацевтической деятельности)                                                                                           |
|      |                         |                        |                                                                                                                                                     |
|      |                         |                        | 3.2. Аптека производственная                                                                                                                        |
|      |                         |                        | ________________________                                                                                                                            |
|      |                         |                        | (адрес места осуществления фармацевтической деятельности)                                                                                           |
|      |                         |                        |                                                                                                                                                     |
|      |                         |                        | 3.3. Аптека производственная с правом изготовления асептических лекарственных препаратов                                                            |
|      |                         |                        | ________________________                                                                                                                            |
|      |                         |                        | (адрес места осуществления фармацевтической деятельности)                                                                                           |
|      |                         |                        |                                                                                                                                                     |
|      |                         |                        | 3.4. Аптечный пункт                                                                                                                                 |
|      |                         |                        | ________________________ (адрес места осуществления лицензируемого вида деятельности)                                                               |
|      |                         |                        |                                                                                                                                                     |
|      |                         |                        | __* хранение лекарственных средств для медицинского применения;                                                                                     |
|      |                         |                        | __* хранение лекарственных препаратов для медицинского применения;                                                                                  |
|      |                         |                        | __* перевозка лекарственных препаратов для медицинского применения;                                                                                 |
|      |                         |                        | __* перевозка лекарственных средств для медицинского применения;                                                                                    |
|      |                         |                        | __* розничная торговля лекарственными препаратами для                                                                                               |
|      |                         |                        | медицинского применения;                                                                                                                            |
|——————|—————————————————————————|————————————————————————|—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  1   |            2            |           3            |                                                                          4                                                                          |
|——————|—————————————————————————|————————————————————————|—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|      |                         |                        | __* отпуск лекарственных препаратов для медицинского применения;                                                                                    |
|      |                         |                        | __* изготовление лекарственных препаратов для медицинского применения.                                                                              |
|      |                         |                        |                                                                                                                                                     |
|      |                         |                        | 4. Обособленные подразделения медицинских организаций, расположенных в сельских поселениях, в которых отсутствуют аптечные организации:             |
|      |                         |                        |                                                                                                                                                     |
|      |                         |                        | 4.1. Центр (отделение) общей врачебной (семейной) практики                                                                                          |
|      |                         |                        | ________________________ (адрес места осуществления лицензируемого вида деятельности)                                                               |
|      |                         |                        |                                                                                                                                                     |
|      |                         |                        |  4.2. Амбулатория                                                                                                                                   |
|      |                         |                        | ________________________ (адрес места осуществления лицензируемого вида деятельности)                                                               |
|      |                         |                        |                                                                                                                                                     |
|      |                         |                        | 4.3. Фельдшерский пункт                                                                                                                             |
|      |                         |                        | ________________________ (адрес места осуществления лицензируемого вида деятельности)                                                               |
|      |                         |                        |                                                                                                                                                     |
|      |                         |                        | 4.4. Фельдшерско-акушерский пункт                                                                                                                   |
|      |                         |                        | ________________________ (адрес места осуществления лицензируемого вида деятельности)                                                               |
|      |                         |                        |                                                                                                                                                     |
|      |                         |                        | __* перевозка лекарственных препаратов для медицинского применения;                                                                                 |
|      |                         |                        | __* перевозка лекарственных средств для медицинского применения;                                                                                    |
|——————|—————————————————————————|————————————————————————|—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  1   |            2            |           3            |                                                                          4                                                                          |
|——————|—————————————————————————|————————————————————————|—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|      |                         |                        | __* розничная торговля лекарственными препаратами для медицинского применения;                                                                      |
|      |                         |                        | __* отпуск лекарственных препаратов для медицинского применения;                                                                                    |
|      |                         |                        | __* изготовление лекарственных препаратов для медицинского применения.                                                                              |
|      |                         |                        |                                                                                                                                                     |
|      |                         |                        | 5. Индивидуальные предприниматели                                                                                                                   |
|      |                         |                        |                                ________________________ (адрес места осуществления лицензируемого вида деятельности)                                |
|      |                         |                        | __* хранение лекарственных средств для медицинского применения;                                                                                     |
|      |                         |                        | __* хранение лекарственных препаратов для медицинского применения;                                                                                  |
|      |                         |                        | __* перевозка лекарственных препаратов для медицинского применения;                                                                                 |
|      |                         |                        | __* перевозка лекарственных средств для медицинского применения;                                                                                    |
|      |                         |                        | __* розничная торговля лекарственными препаратами для медицинского применения;                                                                      |
|      |                         |                        | __* отпуск лекарственных препаратов для медицинского применения;                                                                                    |
|      |                         |                        | __* изготовление лекарственных препаратов для медицинского применения.                                                                              |
|      |                         |                        |                                                                                                                                                     |
|      |                         |                        | 6. Иные организации, осуществляющие                                                                                                                 |
|——————|—————————————————————————|————————————————————————|—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  1   |            2            |           3            |                                                                          4                                                                          |
|——————|—————————————————————————|————————————————————————|—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|      |                         |                        | обращение лекарственных средств                                                                                                                     |
|      |                         |                        | ________________________ (адрес места осуществления лицензируемого вида деятельности)                                                               |
|      |                         |                        | __* хранение лекарственных средств для медицинского применения;                                                                                     |
|      |                         |                        | __* хранение лекарственных препаратов для медицинского применения;                                                                                  |
|      |                         |                        | __* перевозка лекарственных препаратов для медицинского применения;                                                                                 |
|      |                         |                        | __* перевозка лекарственных средств для медицинского применения;                                                                                    |
|      |                         |                        | __* розничная торговля лекарственными препаратами для медицинского применения;                                                                      |
|      |                         |                        | __* отпуск лекарственных препаратов для медицинского применения;                                                                                    |
|      |                         |                        | __* изготовление лекарственных препаратов для медицинского применения                                                                               |
|      |                         |                        |                                                                                                                                                     |
|——————|—————————————————————————|————————————————————————|—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 13.  | Номер телефона (в       |                        |                                                                                                                                                     |
|      | случае, если имеется),  |                        |                                                                                                                                                     |
|      | адрес электронной почты |                        |                                                                                                                                                     |
|——————|—————————————————————————|————————————————————————|—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 14.  | Форма получения         | __* на бумажном носителе лично;                                                                                                                                              |
|      | переоформленной         | __* на бумажном носителе направить заказным почтовым отправлением с уведомлением о вручении;                                                                                 |
|      | лицензии                | __* в форме электронного документа                                                                                                                                           |
|——————|—————————————————————————|——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
* Нужное отметить

II. В связи:
__* с  изменением  адресов  мест  осуществления  лицензируемого   вида
деятельности;
__* изменением   перечня   выполняемых   работ,   оказываемых   услуг,
составляющих  лицензируемый вид  деятельности,  ранее не  указанных  в
лицензии;
__* прекращением деятельности по одному адресу или нескольким  адресам
мест осуществления деятельности, указанным в лицензии;
__* прекращением деятельности  выполняемых  работ, оказываемых  услуг,
составляющих лицензируемый вид деятельности;
__* истечением срока действия  лицензии (лицензий), не содержащей  (не
содержащих) перечня выполняемых работ, оказываемых услуг, составляющих
лицензируемый вид деятельности.
     
|—————————|———————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|   1.    | Организационно-правовая форма |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | и полное наименование         |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | юридического лица             |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|—————————|———————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|   2.    | Сокращенное наименование      |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | юридического лица (в случае,  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | если имеется)                 |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|—————————|———————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|   3.    | Фирменное наименование        |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | юридического лица (в случае,  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | если имеется)                 |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|—————————|———————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|   4.    | Адрес местонахождения         |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | юридического лица             |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|—————————|———————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|   5.    | Государственный               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | регистрационный номер записи  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | о создании юридического лица  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|—————————|———————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|   6.    | Идентификационный номер       |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | налогоплательщика             |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|—————————|———————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|   7.    | Номер телефона (в случае,     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | если имеется), адрес          |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | электронной почты             |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|—————————|———————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|   8.    | Форма получения               | __* на бумажном носителе лично;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|         | переоформленной лицензии      | __* на бумажном носителе направить заказным почтовым отправлением с уведомлением о вручении;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           |
|         |                               | __* в форме электронного документа                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     |
|         |                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|—————————|———————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|   9.    | __* изменением адресов мест осуществления лицензируемого вида деятельности                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             |