Příloha č. 4 x xxxxxxxx x. 467/2003 Xx.
Xxxx tiskopisu pro xxxxxxxx xxxxxxxxxx xxxxxxx
XXXXX
x xxxxxxxxx, xxxxxxx a xxxxxxxxx xxxxxxxxxx nálepkách xx xxxxxxxx xxxxxxx
1. Xxxxx xxxxxxxxx xxxxxxxxxx xxxxxxx
x) xxx xxxxxxxx
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Obsah xxxxxx Xxxx pro konečného Množství
(xx) xxxxxxxxxxxx xx xxxxxx
____________________________________________________________________________________________
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Xxxxx xxxxxxx: CELKEM:
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Datum xxxxxxxx Xxxxx x xxxxxx xxxxxx xxxxx pověřeného xxxxxxx xxxxx:
x) pro xxxxxxxx x cigarillos
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxxxxx
(xx)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x xxxxxx xxxxxx xxxxx pověřeného xxxxxxx xxxxx:
x) xxx xxxxx xx kouření
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxxxxx
(kg)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: CELKEM:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx a podpis xxxxxx xxxxx pověřeného xxxxxxx úřadu:
2. Xxxxx xxxxx xxxxxxxxxx nálepek ve xxxxxx xx xxxxxxx xxxxx Xxxxx republiky
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Xxxxx vydání Xxxxx Xxxx xxx Xxxxx xxxxxxxxxx xxxxxxx v kusech
xx xxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxx xx xxxxxxxx xxxxxxxxxxx
xx balení do xxxxxx xxxxxxx
xxxxxxx
____________________________________________________________________________________________
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Počet xxxxxxx: XXXXXX:
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3. Výkaz užití xxxxxxxxxx nálepek xxxx xxxxxx xxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx Xxxx xxx Xxxxx xxxxxxxxxx xxxxxxx x kusech
xxxxxx xxxxxxxxx ________________________________________________
(ks, xx) xxxxxxxxxxxx xxxxxxxxx xxxx xxxxxxxx xxxxxxx xxxxxxxxxxx
xx xxxxxx xxxxxx xxxxx xxxx xxxxxx xxxxx
xxxxxxx Xxxxx republiky České xxxxxxxxx
____________________________________________________________________________________________
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Xxxxx položek: XXXXXX:
____________________________________________________________________________________________
4. Xxxxx xxxxxxxxx xxxxxxxxxxx tabákových nálepek
____________________________________________________________________________________________
Xxxxx Xxxxx Cena xxx Xxxxx tabákových xxxxxxx x xxxxxx
xxxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxxx xxxxxx xxxxxx xxxxxxxx
xx xxxxxx
xxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx: Xxxxxxx x xxxxxx
xxxxxxxxxx