Xxxxxxxx xx 14.7.2005 xx 3.4.2007 (do xxxxxx x. 72/2007 Xx.)
Xxxxxxx x. 4 x vyhlášce x. 467/2003 Sb.
Vzor tiskopisu xxx xxxxxxxx xxxxxxxxxx xxxxxxx
XXXXX
x xxxxxxxxx, užitých x vrácených tabákových xxxxxxxxx xx xxxxxxxx xxxxxxx
1. Xxxxx xxxxxxxxx xxxxxxxxxx xxxxxxx
x) xxx xxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxx pro xxxxxxxxx Xxxxxxxx
(xx) xxxxxxxxxxxx za xxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: CELKEM:
____________________________________________________________________________________________
Datum xxxxxxxx Xxxxx x xxxxxx zaměstnance xxxxxxxx xxxxxxx xxxxx:
x) xxx doutníky x xxxxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxxxxx
(xx)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx položek: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x xxxxxx zaměstnance xxxxxxxx xxxxxxx úřadu:
c) xxx xxxxx
____________________________________________________________________________________________
Xxxxx balení Množství
(kg)
____________________________________________________________________________________________
____________________________________________________________________________________________
Počet xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x xxxxxx xxxxxxxxxxx pověřeho xxxxxxx xxxxx:
2. Výkaz xxxxx xxxxxxxxxx xxxxxxx xx xxxxxx na xxxxxxx území Xxxxx xxxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxx Obsah Xxxx xxx Xxxxx xxxxxxxxxx xxxxxxx x xxxxxx
xx xxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, kg) spotřebitele vydaných xx xxxxxxxx xxxxxxxxxxx
xx xxxxxx xx výroby užitých
cigaret
____________________________________________________________________________________________
____________________________________________________________________________________________
Počet xxxxxxx: XXXXXX:
____________________________________________________________________________________________
3. Výkaz xxxxx xxxxxxxxxx nálepek xxxx xxxxxx xxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
Xxxxx odeslání Obsah Xxxx xxx Xxxxx xxxxxxxxxx xxxxxxx v xxxxxx
xxxxxx xxxxxxxxx ________________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxxx xxxx xxxxxxxx xxxxxxx xxxxxxxxxxx
xx xxxxxx xxxxxx území xxxx xxxxxx xxxxx
xxxxxxx Xxxxx republiky České xxxxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: CELKEM:
____________________________________________________________________________________________
4. Xxxxx xxxxxxxxx poškozených xxxxxxxxxx xxxxxxx
____________________________________________________________________________________________
Xxxxx Xxxxx Xxxx xxx Xxxxx xxxxxxxxxx xxxxxxx x kusech
vrácení balení konečného __________________________________________
(xx, kg) spotřebitele vrácených xxxxxx xxxxxx xxxxxxxx
xx xxxxxx
xxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx položek: XXXXXX:
____________________________________________________________________________________________
Xxxxx: Xxxxxxx a xxxxxx
xxxxxxxxxx