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<!doctype html>
<html lang="en">
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1, shrink-to-fit=no">
<meta name="robots" content="index, follow">
<meta name="description" content="Descărcă de aici declarația pe propria răspundere în vederea deplasării pe teritoriul României, în contextul pandemiei de coronavirus.">
<meta property="og:url" content="https://alexandrubau.github.io/declar">
<meta property="og:title" content="Descarcă declarația pe propria raspundere">
<meta property="og:description" content="Descărcă de aici declarația pe propria răspundere în vederea deplasării pe teritoriul României, în contextul pandemiei de coronavirus.">
<meta property="og:image" content="https://alexandrubau.github.io/declar/assets/img/fb_cover.jpg">
<link rel="stylesheet" href="https://cdn.jsdelivr.net/npm/[email protected]/dist/css/bootstrap.min.css">
<link rel="stylesheet" href="https://cdn.jsdelivr.net/npm/@chenfengyuan/[email protected]/dist/datepicker.min.css">
<title>Declarație pe propria răspundere pentru deplasare | COVID-19</title>
</head>
<body>
<div class="container mt-3">
<div class="jumbotron text-center">
<h1 class="display-4">Declarație pe propria răspundere</h1>
<p class="lead">Folosește această aplicație pentru a descărca declarația pe propria răspundere în vederea deplasării pe teritoriul României, în contextul pandemiei de coronavirus.</p>
<hr class="my-4">
<p>Ai încredere că datele tale personale sunt în siguranță. Acestea nu sunt transmise prin internet și nu părăsesc niciodată dispozitivul de pe care completezi.</p>
<a class="btn btn-primary btn-lg" href="#begin" role="button">Începe completarea »</a>
</div>
<div class="col-12 p-0">
<form>
<h3 id="begin">Date personale</h3>
<p class="small text-muted">Completați cu datele din buletin.</p>
<hr>
<div class="js-form-person">
<div class="form-row">
<div class="form-group col-sm-12 col-md-6">
<label for="form_id_lastname">Nume</label>
<input type="text" class="form-control" name="form_id_lastname" id="form_id_lastname" required>
</div>
<div class="form-group col-sm-12 col-md-6">
<label for="form_id_firstname">Prenume</label>
<input type="text" class="form-control" name="form_id_firstname" id="form_id_firstname" required>
</div>
</div>
<div class="form-row">
<div class="form-group col-sm-12 col-md-6">
<label for="form_fathername">Prenume Tată</label>
<input type="text" class="form-control" name="form_fathername" id="form_fathername" required>
</div>
<div class="form-group col-sm-12 col-md-6">
<label for="form_mothername">Prenume Mamă</label>
<input type="text" class="form-control" name="form_mothername" id="form_mothername" required>
</div>
</div>
<div class="form-group">
<label for="form_pnc">CNP</label>
<input type="text" class="form-control" name="form_pnc" id="form_pnc" required>
</div>
<div class="form-row">
<div class="form-group col-sm-12 col-md-6">
<label for="form_id_series">Serie</label>
<input type="text" class="form-control" name="form_id_series" id="form_id_series" required>
</div>
<div class="form-group col-sm-12 col-md-6">
<label for="form_id_number">Număr</label>
<input type="text" class="form-control" name="form_id_number" id="form_id_number" required>
</div>
</div>
</div>
<h3>Domiciliu</h3>
<p class="small text-muted">Completați cu datele din buletin.</p>
<hr>
<div class="js-form-home">
<div class="form-row">
<div class="form-group col-sm-12 col-md-6">
<label for="form_id_city">Localitate</label>
<input type="text" class="form-control" name="form_id_city" id="form_id_city" required>
</div>
<div class="form-group col-sm-12 col-md-6">
<label for="form_id_county">Județ/Sector</label>
<input type="text" class="form-control" name="form_id_county" id="form_id_county" required>
</div>
</div>
<div class="form-row">
<div class="form-group col-9">
<label for="form_id_street">Stradă</label>
<input type="text" class="form-control" name="form_id_street" id="form_id_street" required>
</div>
<div class="form-group col-3">
<label for="form_id_street_no">Număr</label>
<input type="text" class="form-control" name="form_id_street_no" id="form_id_street_no" required>
</div>
</div>
<div class="form-row">
<div class="form-group col-6 col-md-3">
<label for="form_id_building">Bloc</label>
<input type="text" class="form-control" name="form_id_building" id="form_id_building">
</div>
<div class="form-group col-6 col-md-3">
<label for="form_id_building_entrance">Scară</label>
<input type="text" class="form-control" name="form_id_building_entrance" id="form_id_building_entrance">
</div>
<div class="form-group col-6 col-md-3">
<label for="form_id_building_floor">Etaj</label>
<input type="text" class="form-control" name="form_id_building_floor" id="form_id_building_floor">
</div>
<div class="form-group col-6 col-md-3">
<label for="form_id_appartment_no">Apartament</label>
<input type="text" class="form-control" name="form_id_appartment_no" id="form_id_appartment_no">
</div>
</div>
</div>
<h3>Reședinta</h3>
<p class="small text-muted">Completați adresa la care locuiți.</p>
<hr>
<div class="js-form-residence">
<div class="form-group form-check">
<input type="checkbox" class="form-check-input" name="form_address_same" id="form_address_same">
<label class="form-check-label" for="form_address_same">Locuiesc la adresa din buletin</label>
</div>
<div class="form-row">
<div class="form-group col-sm-12 col-md-6">
<label for="form_city">Localitate</label>
<input type="text" class="form-control" name="form_city" id="form_city" required>
</div>
<div class="form-group col-sm-12 col-md-6">
<label for="form_county">Județ/Sector</label>
<input type="text" class="form-control" name="form_county" id="form_county" required>
</div>
</div>
<div class="form-row">
<div class="form-group col-9">
<label for="form_street">Stradă</label>
<input type="text" class="form-control" name="form_street" id="form_street" required>
</div>
<div class="form-group col-3">
<label for="form_street_no">Număr</label>
<input type="text" class="form-control" name="form_street_no" id="form_street_no" required>
</div>
</div>
<div class="form-row">
<div class="form-group col-6 col-md-3">
<label for="form_building">Bloc</label>
<input type="text" class="form-control" name="form_building" id="form_building">
</div>
<div class="form-group col-6 col-md-3">
<label for="form_building_entrance">Scară</label>
<input type="text" class="form-control" name="form_building_entrance" id="form_building_entrance">
</div>
<div class="form-group col-6 col-md-3">
<label for="form_building_floor">Etaj</label>
<input type="text" class="form-control" name="form_building_floor" id="form_building_floor">
</div>
<div class="form-group col-6 col-md-3">
<label for="form_appartment_no">Apartament</label>
<input type="text" class="form-control" name="form_appartment_no" id="form_appartment_no">
</div>
</div>
</div>
<h3>Itinerariu</h3>
<p class="small text-muted">Completați detaliile despre itinerariu.</p>
<hr>
<div class="js-form-itinerary">
<div class="form-group">
<label for="form_from">Punct de plecare</label>
<input type="text" class="form-control" name="form_from" id="form_from" required>
<small id="form_from_help" class="form-text text-muted">Introduceți locul din care plecați. Exemplu: domiciliu</small>
</div>
<div class="form-group">
<label for="form_to">Destinație</label>
<input type="text" class="form-control" name="form_to" id="form_to" required>
<small id="form_to_help" class="form-text text-muted">Introduceți locul în care doriți să ajungeți. Exemplu: farmacie</small>
</div>
<div class="form-row">
<div class="form-group col-sm-12 col-md-6">
<label for="form_start_hour">Începând cu ora</label>
<div class="input-group">
<select class="form-control mx-2" name="form_start_hour" id="form_start_hour">
<option>00</option>
<option>01</option>
<option>02</option>
<option>03</option>
<option>04</option>
<option>05</option>
<option>06</option>
<option>07</option>
<option>08</option>
<option>09</option>
<option selected>10</option>
<option>11</option>
<option>12</option>
<option>13</option>
<option>14</option>
<option>15</option>
<option>16</option>
<option>17</option>
<option>18</option>
<option>19</option>
<option>20</option>
<option>21</option>
<option>22</option>
<option>23</option>
</select>
<select class="form-control mx-2" name="form_start_minute" id="form_start_minute">
<option>00</option>
<option>15</option>
<option>30</option>
<option>45</option>
</select>
</div>
</div>
<div class="form-group col-sm-12 col-md-6">
<label for="form_end_hour">Până la ora</label>
<div class="input-group">
<select class="form-control mx-2" name="form_end_hour" id="form_end_hour">
<option>00</option>
<option>01</option>
<option>02</option>
<option>03</option>
<option>04</option>
<option>05</option>
<option>06</option>
<option>07</option>
<option>08</option>
<option>09</option>
<option>10</option>
<option selected>11</option>
<option>12</option>
<option>13</option>
<option>14</option>
<option>15</option>
<option>16</option>
<option>17</option>
<option>18</option>
<option>19</option>
<option>20</option>
<option>21</option>
<option>22</option>
<option>23</option>
</select>
<select class="form-control mx-2" name="form_end_minute" id="form_end_minute">
<option>00</option>
<option>15</option>
<option>30</option>
<option>45</option>
</select>
</div>
</div>
</div>
<div class="form-group">
<label>Motivul deplasării</label>
<div class="form-check">
<input class="form-check-input" type="radio" name="form_reason" id="form_reason_1" value="reason_1" required>
<label class="form-check-label" for="form_reason_1">
deplasarea între domiciliu și locul de muncă, atunci când activitatea profesională
este esențială și nu poate fi organizată sub formă de lucru la distanță sau deplasarea în interes
profesional care nu poate fi amânată;
</label>
</div>
<div class="form-check">
<input class="form-check-input" type="radio" name="form_reason" id="form_reason_2" value="reason_2">
<label class="form-check-label" for="form_reason_2">
consult medical de specialitate care nu poate fi amânat;
</label>
</div>
<div class="form-check">
<input class="form-check-input" type="radio" name="form_reason" id="form_reason_3" value="reason_3">
<label class="form-check-label" for="form_reason_3">
deplasare pentru cumpărături de primă necesitate la unități comerciale din zona de domiciliu;
</label>
</div>
<div class="form-check">
<input class="form-check-input" type="radio" name="form_reason" id="form_reason_4" value="reason_4">
<label class="form-check-label" for="form_reason_4">
deplasare pentru asigurarea asistenței pentru persoane în vârstă, vulnerabile sau
pentru însoțirea copiilor;
</label>
</div>
<div class="form-check">
<input class="form-check-input" type="radio" name="form_reason" id="form_reason_5" value="reason_5">
<label class="form-check-label" for="form_reason_5">
deplasare scurtă, lângă domiciliu, pentru desfășurarea de activități fizice individuale,
în aer liber, cu excluderea oricărei forme de activitate sportivă colectivă;
</label>
</div>
<div class="form-check">
<input class="form-check-input" type="radio" name="form_reason" id="form_reason_6" value="reason_6">
<label class="form-check-label" for="form_reason_6">
deplasare scurtă, lângă domiciliu, legată de nevoile animalelor de companie
</label>
</div>
<div class="form-check">
<input class="form-check-input" type="radio" name="form_reason" id="form_reason_other" value="reason_other">
<label class="form-check-label" for="form_reason_other">
deplasare pentru rezolvarea următoarei situații urgente
</label>
</div>
</div>
<div class="form-group">
<label for="form_emergency_details">Detalii situație de urgență</label>
<textarea class="form-control" name="form_emergency_details" id="form_emergency_details" rows="2" disabled></textarea>
</div>
<div class="form-group">
<label for="form_date">Data</label>
<input type="text" class="form-control" name="form_date" id="form_date" required>
</div>
</div>
<h3>Semnătură</h3>
<p class="small text-muted">Folosiți degetul sau cursorul pentru a semna.</p>
<hr>
<div style="height: 200px;">
<canvas class="w-100 h-100"></canvas>
</div>
<a href="javascript:void(0);" class="btn btn-secondary btn-block" id="form-signature-clear">Șterge semnătura</a>
<button type="submit" class="btn btn-success btn-block">Descarcă declarație</button>
</form>
</div>
<p class="small text-muted text-center mt-3">
Această aplicație a fost creată de voluntari. <br>
Dorești să te implici? Vezi pe <a href="https://github.com/alexandrubau/declar" target="_blank">Github</a> codul sursă al aplicației. <br>
#StamAcasa
</p>
</div>
<script src="https://cdn.jsdelivr.net/npm/[email protected]/dist/jquery.min.js"></script>
<script src="https://cdn.jsdelivr.net/npm/[email protected]/dist/js/bootstrap.bundle.min.js"></script>
<script src="https://cdn.jsdelivr.net/npm/[email protected]/dist/jspdf.min.js"></script>
<script src="https://cdn.jsdelivr.net/npm/[email protected]/dist/signature_pad.min.js"></script>
<script src="https://cdn.jsdelivr.net/npm/@chenfengyuan/[email protected]/dist/datepicker.min.js"></script>
<script src="assets/js/font.js"></script>
<script src="assets/js/script.js"></script>
</body>
</html>