Příloha x. 4 x xxxxxxxx x. 467/2003 Xx.
Xxxx tiskopisu pro xxxxxxxx xxxxxxxxxx nálepek
XXXXX
o xxxxxxxxx, xxxxxxx x xxxxxxxxx xxxxxxxxxx nálepkách na xxxxxxxx xxxxxxx
1. Xxxxx přijatých xxxxxxxxxx xxxxxxx
a) pro xxxxxxxx
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Xxxxx xxxxxx Xxxx xxx xxxxxxxxx Xxxxxxxx
(xx) xxxxxxxxxxxx xx balení
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Xxxxx xxxxxxx: XXXXXX:
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Xxxxx xxxxxxxx Xxxxx a podpis xxxxxx xxxxx xxxxxxxxxx xxxxxxx xxxxx:
x) xxx doutníky x xxxxxxxxxx
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Xxxxx balení Množství
(xx)
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Xxxxx xxxxxxx: XXXXXX:
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Xxxxx xxxxxxxx Xxxxx x xxxxxx xxxxxx xxxxx xxxxxxxxxx xxxxxxx xxxxx:
x) pro xxxxx xx xxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxxxxx
(kg)
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Xxxxx položek: XXXXXX:
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Datum xxxxxxxx Xxxxx x xxxxxx xxxxxx xxxxx pověřeného xxxxxxx xxxxx:
2. Xxxxx užití xxxxxxxxxx xxxxxxx ve xxxxxx na xxxxxxx xxxxx Xxxxx republiky
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Xxxxx vydání Xxxxx Xxxx pro Xxxxx tabákových xxxxxxx x xxxxxx
xx xxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, kg) spotřebitele vydaných xx xxxxxxxx xxxxxxxxxxx
xx balení do výroby užitých
xxxxxxx
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Xxxxx xxxxxxx: XXXXXX:
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3. Xxxxx užití xxxxxxxxxx nálepek xxxx xxxxxx xxxxx Xxxxx xxxxxxxxx
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Xxxxx xxxxxxxx Xxxxx Xxxx xxx Xxxxx xxxxxxxxxx xxxxxxx x xxxxxx
xxxxxx xxxxxxxxx ________________________________________________
(ks, xx) xxxxxxxxxxxx xxxxxxxxx xxxx xxxxxxxx xxxxxxx xxxxxxxxxxx
xx xxxxxx xxxxxx xxxxx xxxx daňové xxxxx
xxxxxxx Xxxxx republiky České xxxxxxxxx
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Xxxxx položek: XXXXXX:
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4. Xxxxx vrácených xxxxxxxxxxx xxxxxxxxxx xxxxxxx
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Xxxxx Xxxxx Cena pro Xxxxx xxxxxxxxxx xxxxxxx v kusech
xxxxxxx xxxxxx xxxxxxxxx __________________________________________
(ks, xx) xxxxxxxxxxxx xxxxxxxxx xxxxxx xxxxxx xxxxxxxx
xx xxxxxx
xxxxxxx
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Xxxxx položek: XXXXXX:
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Xxxxx: Xxxxxxx x xxxxxx
xxxxxxxxxx