Xxxxxxx č. 4 x xxxxxxxx x. 467/2003 Sb.
Xxxx xxxxxxxxx xxx xxxxxxxx xxxxxxxxxx xxxxxxx
XXXXX
x xxxxxxxxx, xxxxxxx a xxxxxxxxx xxxxxxxxxx xxxxxxxxx xx xxxxxxxx výrobky
1. Xxxxx přijatých tabákových xxxxxxx
x) xxx xxxxxxxx
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Xxxxx xxxxxx Xxxx pro konečného Množství
(xx) xxxxxxxxxxxx za xxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
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Xxxxx xxxxxxxx Xxxxx a xxxxxx xxxxxx osoby xxxxxxxxxx xxxxxxx úřadu:
x) xxx xxxxxxxx x xxxxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxxxxx
(ks)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x xxxxxx xxxxxx osoby xxxxxxxxxx xxxxxxx xxxxx:
x) xxx tabák xx kouření
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxxxxx
(xx)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx položek: XXXXXX:
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Xxxxx xxxxxxxx Xxxxx a xxxxxx xxxxxx xxxxx pověřeného xxxxxxx xxxxx:
2. Xxxxx užití xxxxxxxxxx xxxxxxx xx xxxxxx xx daňovém xxxxx Xxxxx republiky
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Datum vydání Xxxxx Xxxx xxx Xxxxx xxxxxxxxxx xxxxxxx x kusech
xx xxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxx xx xxxxxxxx xxxxxxxxxxx
xx xxxxxx xx xxxxxx xxxxxxx
xxxxxxx
____________________________________________________________________________________________
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Xxxxx položek: XXXXXX:
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3. Xxxxx užití xxxxxxxxxx nálepek xxxx xxxxxx xxxxx České xxxxxxxxx
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Datum odeslání Obsah Cena xxx Xxxxx xxxxxxxxxx xxxxxxx x xxxxxx
xxxxxx xxxxxxxxx ________________________________________________
(ks, xx) xxxxxxxxxxxx xxxxxxxxx mimo skutečně xxxxxxx xxxxxxxxxxx
za xxxxxx xxxxxx xxxxx xxxx daňové xxxxx
xxxxxxx Xxxxx xxxxxxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
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Počet xxxxxxx: XXXXXX:
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4. Xxxxx xxxxxxxxx xxxxxxxxxxx tabákových xxxxxxx
____________________________________________________________________________________________
Datum Xxxxx Xxxx pro Xxxxx xxxxxxxxxx xxxxxxx x kusech
xxxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxxx xxxxxx xxxxxx xxxxxxxx
xx xxxxxx
xxxxxxx
____________________________________________________________________________________________
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Xxxxx položek: XXXXXX:
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Datum: Razítko x podpis
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