FORMULAR ANKESE

Të dhënat e ankuesit:

Emër:

Mbiemër:
Institucion publik/privat
Vendbanimi:
Adresa:
Nr.kontakti:
Email:

Të dhënat e Psikologut/es ndaj të cilit është drejtuar ankesa:

Emër:
Mbiemër:
Vendbanimi:
Adresa(nese eshte e disponueshme):
Nr.kontakti (nese eshte i disponueshem):
Email (nese eshte i disponueshem):
Emërtimi i institucionit ku punon:

Shpjegimi i qartë i fakteve rreth të cilave bëhet ankesa:

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Kërkesa ankimore duhet të mbështetet me dokumentacionin e nevojshëm provues, të

cilat duhet t’i bashkëngjiten kërkesës.

Dokumenta që i bashkëngjiten ankesës :

(lista e dokumentave të mundshme në të cilat mbështeten pretendimet )

1.________________________________________

2.________________________________________

3.________________________________________

4.________________________________________

5.________________________________________

Data ___/___/_______

Firma e ankuesit

(Emri i plotë dhe nënshkrimi)