Xxxxxxx x. 4 x vyhlášce x. 467/2003 Xx.
Xxxx tiskopisu xxx xxxxxxxx xxxxxxxxxx nálepek
XXXXX
x xxxxxxxxx, xxxxxxx a xxxxxxxxx xxxxxxxxxx xxxxxxxxx na xxxxxxxx xxxxxxx
1. Xxxxx xxxxxxxxx tabákových xxxxxxx
a) xxx xxxxxxxx
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Xxxxx xxxxxx Xxxx xxx xxxxxxxxx Xxxxxxxx
(xx) xxxxxxxxxxxx xx xxxxxx
____________________________________________________________________________________________
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Xxxxx xxxxxxx: CELKEM:
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Xxxxx xxxxxxxx Xxxxx x podpis xxxxxx xxxxx xxxxxxxxxx xxxxxxx xxxxx:
x) xxx xxxxxxxx x xxxxxxxxxx
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Xxxxx balení Množství
(xx)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx položek: XXXXXX:
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Xxxxx xxxxxxxx Xxxxx a podpis xxxxxx xxxxx xxxxxxxxxx xxxxxxx úřadu:
x) pro tabák xx xxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxxxxx
(xx)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
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Datum xxxxxxxx Xxxxx a xxxxxx xxxxxx xxxxx xxxxxxxxxx xxxxxxx xxxxx:
2. Xxxxx užití xxxxxxxxxx xxxxxxx xx xxxxxx na xxxxxxx xxxxx České xxxxxxxxx
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Xxxxx xxxxxx Xxxxx Xxxx xxx Xxxxx tabákových xxxxxxx x kusech
xx xxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, kg) spotřebitele vydaných do skutečně poškozených
xx xxxxxx xx xxxxxx xxxxxxx
xxxxxxx
____________________________________________________________________________________________
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Počet xxxxxxx: XXXXXX:
____________________________________________________________________________________________
3. Xxxxx užití xxxxxxxxxx xxxxxxx xxxx xxxxxx xxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx Xxxx xxx Xxxxx xxxxxxxxxx xxxxxxx x xxxxxx
xxxxxx xxxxxxxxx ________________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxxx xxxx xxxxxxxx xxxxxxx xxxxxxxxxxx
xx balení daňové xxxxx xxxx xxxxxx xxxxx
xxxxxxx Xxxxx xxxxxxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
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4. Xxxxx xxxxxxxxx xxxxxxxxxxx xxxxxxxxxx nálepek
____________________________________________________________________________________________
Xxxxx Xxxxx Xxxx pro Počet xxxxxxxxxx xxxxxxx x xxxxxx
xxxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxxx xxxxxx xxxxxx xxxxxxxx
xx balení
cigaret
____________________________________________________________________________________________
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Xxxxx položek: XXXXXX:
____________________________________________________________________________________________
Xxxxx: Xxxxxxx x podpis
odběratele