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Request for Accommodation in the Home

 

Personal information (person being placed in a home)

DOCUMENTATION REQUIRED FOR SUBMITTING A REQUEST

  • Request for accommodation
  • Statement of payment certified by a notary public
  • Doctor's opinion/certificate
  • Copy of the birth certificate
  • Copy of the ID card
  • Copy of the health insurance and supplemental health insurance card

 

PERSONAL DATA (of the person liable for payment - responsible person for the user)

 

PERSONAL DATA (of the person being placed in the home)

Here you can attach medical documentation (doctor's opinion/confirmation or the latest discharge letter if the user possesses it).

Maximum 5 files.
8 MB limit.
Allowed types: jpg, jpeg, png, pdf, doc, docx, ppt, pptx, rar, zip.

 

DOCUMENTATION REQUIRED FOR SUBMITTING A REQUEST

One file only.
8 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
One file only.
8 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
One file only.
8 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
One file only.
8 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
One file only.
8 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
One file only.
8 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
One file only.
8 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
One file only.
8 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
By using this form, you agree that you are familiar with the privacy rules and accept the collection and processing of personal data provided in the form, without which your request in the form cannot be fulfilled.