Immediate termination on health grounds — fill in online

Employer (addressee)

Company name

Registered office address

Company ID (IČO)

Employee (sender)

Employee

Date of birth

Address and bank account

Permanent address

Work

Date of the employment contract

Job title

Date of the medical opinion

Who issued the medical opinion

Date the opinion was submitted to the employer

Signature

Place of signing

Date of signing

Date received by the employer (optional)