STATEMENT FORM FOR STAFF WORKING AT HEIGHT 
We hereby declare that for the realization of the public procurement of works: Execution of works on the construction of the new University Children's Hospital Tiršova 2 in Belgrade, number OP/75-2023/UCH2, we possess in accordance with the Labor Law ("Official Gazette of RS", no. 24/2005, 61/2005, 54/2009, 32/2013, 75/2014, 13/2017 - US decision, 113/2017 and 95/2018 - authentic interpretation), with the following workers with a medical certificate to work at height:
No.	Name and surname	Ref.number of medical certificate to work at height 	Date of medical certificate	Employer and type of work engagement	

					

					

					

Copy the form in the required number of copies, depending on the number of workers working at height.

Date:                                                                 Signature of the tenderer: