A07-Attachment_2_Application_on_Tax_Registration_of_a_Physical_Person.pdf

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Walter Reed Army Institute of Research (WRAIR) - Bioresearch Support to the Lugar Center, The Republic of Georgia
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W81XWH-16-R-0019
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Attachment 2 Application on Tax Registration of a Physical Person

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(Q,)5')MmoNI-Ol

,)5Gb,)(Qae>,) Application

'l30<00.3MO 30MOb b,),)(Q,)b,)b,)(QM ')MoGbsob / GSoae>ob aab,)bae> on tax registration of a physical person/modification

8')MaobMOMae>aO MM,)5M 1 Registering authority

('1I:J&'!b \J.)8b.:,bb b300oo bCMoo::Ioo :fxn) (specializedstructural unit of RevenueService)

2 05'l3MM8,)GO,)'l30<00.3MO 30MOb aab,)bae> Information about physical person

M,)MOSurname b,)bao Name dSm:p5,)Country

I I I I I OOM':><QM!X>b<Q.:>&<t>.:>bOB <QM,3':jJa!50ao OOM.)<QM!X>b<Q.:>&<t>.:>bOrtJaf>D<::'o 30M.)<QO6M8if>o b.:,oo <QM,3':jJa!500bb.:,b<QaB.:> <t>.:>6M8if>o personal number place of residence indicatedina dtizen's ID name and number of a citizen'sID

I I I I r I

'l30<00.3MO 30MObb,)d8o,)5Me>ob,)(Qoo The place of activityof a physicalperson

I I b,).3M5,)dM 8M5,)Ga8ae>o

I I I I3 Contact data

OD.: D'«B(Y)UO,)

Tel.: E-mail

S,)(Q,)bMae>, MM8 ,)5Gb,)(Qae>ob8M5,)Ga8ae>oaaab,)e>,)8ae>,)bo5,)8(Qsoab, ')Mob bVMMO(Q,)bMO I hereby certify that the information indicated in the application is true, correct and complete

4 'l30<00.3MO30MOb,)5 80b V')M8M8,)(Q5Me>,)<Oa

'l3ae>,)8Mbo 3oMObba8MvaM') m(Moob:3o, m:3:J,VD): _..1-------/----- Signatureof a physicalperson or its authorized representative data (date, month, year)

MOb6MO,)'b:.J &br.Jbo\)()o 30mb bM:.JM.)

[:t. om ,CJ5signature of a person responsibleon the registration date, month, year

6 b')o(Qa5°'l3°.3,)GOM 5M8aMO I IIdentification number r.JObM :J3::I[j50b BMd.)d:.J 'Z30'boJr.JMo 30Mob o:.JBmbs::J3.)oo, B0:.JO>om.) 3oM')(!?Mr>ob (!?.)B.)bOr.JM:.Jr>:.Jo (!?MJr.JB:.J60ob 6MB:.JMo in case of a citizen of a foreign country, the number of ID shall be indicated

Attachment 2

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