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檔案及行政資訊應用申請書(APPLICATION TO ACCESS FILES AND ADMINISTRATIVE INFORMATION)

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法務部行政執行署臺南分署檔案及行政資訊應用申請書

APPLICATION TO ACCESS FILES AND ADMINISTRATIVE INFORMATION

Tainan Branch, Administrative Enforcement Agency, Ministry of Justice

編號No. :

姓名Name

性別Sex

出生年月日Date of Birth

身分證明文件字號

Personal I.D. No.

住(居)所、聯絡電話

Domicile (Residence), Contact Phone No.

自然人申請人Natural Person Applicant:

男Male   □

女Female □

 

 

地址Address:

 

電話Phone: (H)           (O)          

e-mail:

※代理人

※Representative:

 

與申請人關係:

Relationship with applicant:

(              )

男Male   □

女Female □

 

 

地址Address:

 

電話Phone: (H)           (O)          

e-mail:

※法人或非法人團體名稱:                                     

 

※Name of juridical person or non-juridical group:                                        

地址:                                                            

Address:                                                            

(法人或非法人團體之代理人、管理人或代表人資料請填於前開自然人申請人欄位)(Please fill in the information of the agent, manager or representative of juridical person or non-juridical group in the above  natural person applicant column.)

序號

Serial No.

檔號

File No.

檔案名稱或內容要旨

Name of File or Summary of Content

申請項目(可複選)

【閱覽、抄錄】【複製】

Application (tick all that apply)

‘View, Transcribe’  ‘Duplicate’

1

 

 

          

2

 

 

          

3

 

 

          

4

 

 

          

5

 

 

          

6

 

 

          

7

 

 

          

8

 

 

          

9

 

 

          

10

 

 

          

※序號  有使用檔案原件之必要,事由:

※The need and reason why access to the original of Serial No.               is required:

申請目的Purpose of Application:

□個人或利害關係人資料查詢To inquire personal information or as an interested party  □學術研究Academic research

□新聞刊物報導News or publication report □業務參考Reference for business

□其他(請敘明目的)  Other (please explain the purpose in detail):                                                  

此致    法務部行政執行署臺南分署

Respectfully Submitted to Tainan Branch, Administrative Enforcement Agency, Ministry of Justice

 

申請人簽章:                         ※代理人簽章:                        

Signature of Applicant:                  ※Signature of Representative:

申請日期:     

Date of Application:

               

 

 

 

 

 

 

 

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