Příloha č. 4 x vyhlášce x. 467/2003 Xx.
Xxxx tiskopisu xxx xxxxxxxx xxxxxxxxxx xxxxxxx
XXXXX
x xxxxxxxxx, xxxxxxx a xxxxxxxxx xxxxxxxxxx nálepkách na xxxxxxxx výrobky
1. Xxxxx xxxxxxxxx xxxxxxxxxx xxxxxxx
x) xxx xxxxxxxx
____________________________________________________________________________________________
Obsah xxxxxx Xxxx xxx xxxxxxxxx Xxxxxxxx
(xx) xxxxxxxxxxxx za balení
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: CELKEM:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx a xxxxxx xxxxxx osoby xxxxxxxxxx xxxxxxx xxxxx:
x) pro xxxxxxxx x cigarillos
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxxxxx
(ks)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x xxxxxx xxxxxx xxxxx pověřeného xxxxxxx xxxxx:
x) xxx tabák xx xxxxxxx
____________________________________________________________________________________________
Xxxxx balení Množství
(xx)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x xxxxxx xxxxxx osoby pověřeného xxxxxxx úřadu:
2. Xxxxx užití xxxxxxxxxx nálepek xx xxxxxx xx xxxxxxx xxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxx Xxxx xxx Xxxxx tabákových xxxxxxx x xxxxxx
xx výroby balení konečného __________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxx xx xxxxxxxx xxxxxxxxxxx
xx xxxxxx xx výroby užitých
xxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx položek: XXXXXX:
____________________________________________________________________________________________
3. Výkaz užití xxxxxxxxxx nálepek xxxx xxxxxx xxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
Datum xxxxxxxx Xxxxx Xxxx xxx Počet xxxxxxxxxx xxxxxxx x xxxxxx
xxxxxx xxxxxxxxx ________________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxxx mimo skutečně xxxxxxx xxxxxxxxxxx
za xxxxxx xxxxxx xxxxx xxxx xxxxxx xxxxx
xxxxxxx Xxxxx xxxxxxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx položek: XXXXXX:
____________________________________________________________________________________________
4. Výkaz xxxxxxxxx xxxxxxxxxxx xxxxxxxxxx nálepek
____________________________________________________________________________________________
Datum Xxxxx Xxxx pro Xxxxx tabákových xxxxxxx v xxxxxx
xxxxxxx xxxxxx xxxxxxxxx __________________________________________
(ks, xx) xxxxxxxxxxxx xxxxxxxxx celkem uznáno xxxxxxxx
xx balení
cigaret
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: CELKEM:
____________________________________________________________________________________________
Datum: Razítko x xxxxxx
xxxxxxxxxx