Xxxxxxx x. 4 x xxxxxxxx x. 467/2003 Sb.
Xxxx xxxxxxxxx pro xxxxxxxx xxxxxxxxxx xxxxxxx
XXXXX
x přijatých, xxxxxxx x xxxxxxxxx xxxxxxxxxx nálepkách xx xxxxxxxx výrobky
1. Xxxxx přijatých tabákových xxxxxxx
a) xxx xxxxxxxx
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Xxxxx xxxxxx Xxxx pro xxxxxxxxx Xxxxxxxx
(xx) xxxxxxxxxxxx za balení
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x xxxxxx xxxxxx xxxxx xxxxxxxxxx xxxxxxx xxxxx:
x) xxx doutníky x cigarillos
____________________________________________________________________________________________
Xxxxx balení Množství
(xx)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
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Datum xxxxxxxx Xxxxx x xxxxxx xxxxxx osoby xxxxxxxxxx xxxxxxx xxxxx:
x) xxx xxxxx xx kouření
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxxxxx
(xx)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x podpis xxxxxx osoby xxxxxxxxxx xxxxxxx xxxxx:
2. Xxxxx xxxxx xxxxxxxxxx xxxxxxx ve xxxxxx xx xxxxxxx xxxxx Xxxxx republiky
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxx Xxxx pro Xxxxx xxxxxxxxxx xxxxxxx x xxxxxx
xx xxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxx xx xxxxxxxx xxxxxxxxxxx
xx xxxxxx xx xxxxxx xxxxxxx
xxxxxxx
____________________________________________________________________________________________
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Počet xxxxxxx: XXXXXX:
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3. Xxxxx xxxxx xxxxxxxxxx xxxxxxx xxxx xxxxxx území České xxxxxxxxx
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Xxxxx xxxxxxxx Xxxxx Xxxx xxx Xxxxx xxxxxxxxxx xxxxxxx x kusech
xxxxxx xxxxxxxxx ________________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxxx xxxx xxxxxxxx xxxxxxx xxxxxxxxxxx
za xxxxxx xxxxxx xxxxx mimo xxxxxx xxxxx
xxxxxxx Xxxxx republiky České xxxxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx položek: XXXXXX:
____________________________________________________________________________________________
4. Xxxxx xxxxxxxxx xxxxxxxxxxx xxxxxxxxxx xxxxxxx
____________________________________________________________________________________________
Xxxxx Xxxxx Xxxx xxx Xxxxx xxxxxxxxxx xxxxxxx x xxxxxx
xxxxxxx xxxxxx xxxxxxxxx __________________________________________
(ks, xx) xxxxxxxxxxxx xxxxxxxxx celkem uznáno neuznáno
xx xxxxxx
xxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx: Xxxxxxx x podpis
xxxxxxxxxx