Příloha x. 4 x xxxxxxxx x. 467/2003 Xx.
Xxxx xxxxxxxxx xxx xxxxxxxx xxxxxxxxxx xxxxxxx
XXXXX
x xxxxxxxxx, xxxxxxx x xxxxxxxxx xxxxxxxxxx nálepkách xx xxxxxxxx výrobky
1. Xxxxx xxxxxxxxx xxxxxxxxxx xxxxxxx
a) xxx xxxxxxxx
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Xxxxx xxxxxx Xxxx pro konečného Množství
(xx) xxxxxxxxxxxx xx balení
____________________________________________________________________________________________
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Xxxxx xxxxxxx: XXXXXX:
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Datum xxxxxxxx Xxxxx a podpis xxxxxx xxxxx xxxxxxxxxx xxxxxxx xxxxx:
x) xxx doutníky x xxxxxxxxxx
____________________________________________________________________________________________
Xxxxx balení Množství
(xx)
____________________________________________________________________________________________
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Xxxxx xxxxxxx: XXXXXX:
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Xxxxx xxxxxxxx Xxxxx x xxxxxx xxxxxx osoby xxxxxxxxxx xxxxxxx xxxxx:
x) xxx xxxxx xx kouření
____________________________________________________________________________________________
Xxxxx balení Množství
(xx)
____________________________________________________________________________________________
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Xxxxx položek: XXXXXX:
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Xxxxx xxxxxxxx Xxxxx x xxxxxx xxxxxx osoby xxxxxxxxxx xxxxxxx úřadu:
2. Výkaz xxxxx xxxxxxxxxx xxxxxxx ve xxxxxx na xxxxxxx xxxxx Xxxxx xxxxxxxxx
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Xxxxx xxxxxx Xxxxx Xxxx xxx Počet tabákových xxxxxxx x xxxxxx
xx xxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxx xx xxxxxxxx xxxxxxxxxxx
xx xxxxxx xx xxxxxx xxxxxxx
xxxxxxx
____________________________________________________________________________________________
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Xxxxx xxxxxxx: XXXXXX:
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3. Výkaz užití xxxxxxxxxx xxxxxxx xxxx xxxxxx území České xxxxxxxxx
____________________________________________________________________________________________
Xxxxx odeslání Obsah Xxxx xxx Xxxxx tabákových xxxxxxx x xxxxxx
xxxxxx xxxxxxxxx ________________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxxx mimo skutečně užitých xxxxxxxxxxx
xx xxxxxx xxxxxx xxxxx xxxx xxxxxx xxxxx
xxxxxxx Xxxxx republiky České xxxxxxxxx
____________________________________________________________________________________________
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Xxxxx xxxxxxx: XXXXXX:
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4. Xxxxx xxxxxxxxx xxxxxxxxxxx xxxxxxxxxx nálepek
____________________________________________________________________________________________
Datum Xxxxx Xxxx xxx Xxxxx xxxxxxxxxx xxxxxxx v xxxxxx
xxxxxxx xxxxxx xxxxxxxxx __________________________________________
(ks, xx) xxxxxxxxxxxx xxxxxxxxx celkem uznáno neuznáno
xx balení
xxxxxxx
____________________________________________________________________________________________
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Xxxxx xxxxxxx: CELKEM:
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Datum: Razítko x xxxxxx
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