Xxxxxxxx xx 14.7.2005 xx 3.4.2007 (xx xxxxxx x. 72/2007 Xx.)
Xxxxxxx x. 4 x vyhlášce x. 467/2003 Sb.
Vzor xxxxxxxxx xxx xxxxxxxx xxxxxxxxxx xxxxxxx
XXXXX
x xxxxxxxxx, užitých x vrácených xxxxxxxxxx xxxxxxxxx xx xxxxxxxx xxxxxxx
1. Výkaz přijatých xxxxxxxxxx xxxxxxx
x) pro xxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxx pro xxxxxxxxx Xxxxxxxx
(xx) xxxxxxxxxxxx xx xxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x xxxxxx zaměstnance xxxxxxxx xxxxxxx xxxxx:
x) xxx xxxxxxxx x xxxxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxxxxx
(xx)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x xxxxxx xxxxxxxxxxx xxxxxxxx xxxxxxx úřadu:
c) pro xxxxx
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxxxxx
(xx)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x xxxxxx xxxxxxxxxxx xxxxxxxx xxxxxxx xxxxx:
2. Výkaz xxxxx tabákových nálepek xx xxxxxx xx xxxxxxx xxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxx Obsah Xxxx xxx Xxxxx xxxxxxxxxx nálepek x xxxxxx
xx xxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, kg) spotřebitele vydaných xx xxxxxxxx xxxxxxxxxxx
xx xxxxxx xx xxxxxx xxxxxxx
xxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx položek: XXXXXX:
____________________________________________________________________________________________
3. Výkaz xxxxx xxxxxxxxxx nálepek mimo xxxxxx xxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx Xxxx xxx Počet xxxxxxxxxx nálepek v xxxxxx
xxxxxx xxxxxxxxx ________________________________________________
(ks, xx) xxxxxxxxxxxx xxxxxxxxx xxxx xxxxxxxx xxxxxxx poškozených
za xxxxxx xxxxxx xxxxx mimo xxxxxx xxxxx
xxxxxxx Xxxxx republiky České xxxxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
4. Xxxxx vrácených xxxxxxxxxxx xxxxxxxxxx xxxxxxx
____________________________________________________________________________________________
Xxxxx Xxxxx Xxxx pro Xxxxx xxxxxxxxxx xxxxxxx x xxxxxx
xxxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, kg) spotřebitele vrácených celkem uznáno xxxxxxxx
xx xxxxxx
xxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx: Xxxxxxx a podpis
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