Xxxxxxx x. 4 x xxxxxxxx x. 467/2003 Xx.
Xxxx xxxxxxxxx xxx xxxxxxxx xxxxxxxxxx xxxxxxx
XXXXX
o přijatých, xxxxxxx a xxxxxxxxx xxxxxxxxxx xxxxxxxxx na xxxxxxxx xxxxxxx
1. Xxxxx xxxxxxxxx tabákových xxxxxxx
x) xxx xxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxx xxx xxxxxxxxx Xxxxxxxx
(xx) xxxxxxxxxxxx za xxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx a podpis xxxxxx xxxxx xxxxxxxxxx xxxxxxx xxxxx:
x) xxx doutníky x cigarillos
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxxxxx
(xx)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: CELKEM:
____________________________________________________________________________________________
Datum xxxxxxxx Xxxxx a xxxxxx xxxxxx xxxxx xxxxxxxxxx xxxxxxx úřadu:
x) pro xxxxx xx kouření
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxxxxx
(xx)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx položek: XXXXXX:
____________________________________________________________________________________________
Datum xxxxxxxx Xxxxx x podpis xxxxxx osoby pověřeného xxxxxxx úřadu:
2. Xxxxx xxxxx xxxxxxxxxx xxxxxxx ve xxxxxx xx xxxxxxx xxxxx České xxxxxxxxx
____________________________________________________________________________________________
Datum vydání Xxxxx Xxxx pro Počet xxxxxxxxxx xxxxxxx v xxxxxx
xx xxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxx do skutečně poškozených
xx xxxxxx xx xxxxxx xxxxxxx
xxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
3. Xxxxx užití xxxxxxxxxx xxxxxxx xxxx xxxxxx xxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx Xxxx xxx Xxxxx tabákových xxxxxxx x xxxxxx
xxxxxx xxxxxxxxx ________________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxxx mimo skutečně užitých xxxxxxxxxxx
xx xxxxxx xxxxxx xxxxx xxxx xxxxxx xxxxx
cigaret České xxxxxxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Počet xxxxxxx: XXXXXX:
____________________________________________________________________________________________
4. Xxxxx vrácených xxxxxxxxxxx xxxxxxxxxx xxxxxxx
____________________________________________________________________________________________
Xxxxx Xxxxx Xxxx pro Počet xxxxxxxxxx xxxxxxx v kusech
xxxxxxx xxxxxx xxxxxxxxx __________________________________________
(ks, xx) xxxxxxxxxxxx xxxxxxxxx xxxxxx xxxxxx xxxxxxxx
xx balení
cigaret
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Datum: Razítko x podpis
xxxxxxxxxx