Právní předpis byl sestaven k datu 14.04.2014.
Zobrazené znění právního předpisu je účinné od 11.04.2006 do 14.04.2014.
Vyhláška, kterou se stanoví tiskopisy formulářů podle zákona č. 167/98 Sb., o návykových látkách a o změně některých dalších zákonů, ve znění pozdějších předpisů
125/2006 Sb.
Účinnost §2
Příloha č. 1 - Žádost o vydání povolení k zacházení s návykovými látkami a přípravky
Příloha č. 2 - Žádost o vydání povolení k zacházení s prekursory - licence
Příloha č. 3 - Žádost o zařazení do seznamu právnických a fyzických osob s uvedením jejich pracovišť, pro jejichž činnost se nevyžaduje povolení k zacházení s návykovými látkami, přípravky je obsahujícími a prekursory
Příloha č. 4 - Žádost o změnu povolení k zacházení s návykovými látkami a přípravky (pouze změna odpovědné osoby)
Příloha č. 5 - Žádost o zrušení povolení k zacházení s návykovými látkami a přípravky
Příloha č. 6 - Žádost o registraci výrobce pomocných látek uvedených v kategorii 2
Příloha č. 7 - Žádost o registraci vývozce pomocných látek uvedených v kategorii 2 a 3
Příloha č. 8 - Žádost o registraci dovozce pomocných látek uvedených v kategorii 2
Příloha č. 9 - Žádost o registraci osoby hodlající uvádět na trh pomocné látky uvedené v kategorii 2
Příloha č. 10 - Žádost o vydání povolení k vývozu návykových látek a přípravků
Příloha č. 11 - Žádost o vydání povolení k vývozu prekursoru
Příloha č. 12 - Žádost o vydání povolení k vývozu pomocné látky
Příloha č. 13 - Žádost o vydání povolení k vývozu pomocné látky zjednodušeným postupem
Příloha č. 14 - Žádost o vydání povolení k dovozu návykových látek a přípravků
Příloha č. 15 - Žádost o vydání povolení k dovozu prekursoru
Příloha č. 16 - Žádost o vydání povolení k vývozu makoviny
Příloha č. 17 - Žádost o vydání povolení k dovozu makoviny
Příloha č. 18 - Měsíční hlášení o uskutečněném dovozu návykových látek a přípravků
Příloha č. 19 - Hlášení o uskutečněném dovozu prekursorů
Příloha č. 20 - Měsíční hlášení o uskutečněnémí vývozu návykových látek a přípravků
Příloha č. 21 - Hlášení o uskutečněném vývozu prekursorů
Příloha č. 22 - Hlášení o uskutečněném vývozu pomocných látek
Příloha č. 23 - Čtvrtletní hlášení o uskutečněném vývozu makoviny
Příloha č. 24 - Čtvrtletní hlášení o uskutečněném dovozu makoviny
Příloha č. 25 - Roční hlášení o zacházení s návykovými látkami, přípravky a prekursory - Souhrn
Příloha č. 26 - Roční hlášení o zacházení s návykovými látkami, přípravky a prekursory - Příloha č. I Příjem od dodavatelů v tuzemsku
Příloha č. 27 - Roční hlášení o zacházení s návykovými látkami, přípravky a prekursory - Příloha č. II Výdej odběratelům v tuzemsku (mimo lékáren)
Příloha č. 28 - Roční hlášení o zacházení s návykovými látkami, přípravky a prekursory - Příloha č. III Detail výroby
Příloha č. 29 - Roční hlášení o zacházení s návykovými látkami, přípravky a prekursory - Příloha č. IV Výroba - výdej vlastnímu podniku
Příloha č. 30 - Roční hlášení o zacházení s návykovými látkami, přípravky a prekursory - Příloha č. V Výroba - detail stavů zásob
Příloha č. 31 - Roční hlášení osob provozujících lékárnu o příjmu, výdeji a stavu zásob omamných látek
Příloha č. 32 - Roční hlášení o výrobě pomocných látek - Souhrn
Příloha č. 33 - Roční hlášení o výrobě pomocných látek - Příloha č. I Detail spotřebovaného množství pro vlastní účely
Příloha č. 34 - Roční hlášení o vývozu pomocných látek - Souhrn
Příloha č. 35 - Roční hlášení o vývozu pomocných látek Příloha č. I Detail celkového vyvezeného množství
Příloha č. 36 - Roční hlášení o dovozu pomocných látek uvedených v kategorii 2 - Souhrn
Příloha č. 37 - Roční hlášení o dovozu pomocných látek uvedených v kategorii 2 - Příloha č. I Detail celkového dovezeného množství
Příloha č. 38 - Roční hlášení o dovozu pomocných látek uvedených v kategorii 2 - Příloha č. II Detail spotřebovaného množství pro vlastní účely
Příloha č. 39 - Roční hlášení o pěstování máku setého a konopí
Příloha č. 40 - Oseté plochy a jejich odhad pěstování máku setého a konopí
Příloha č. 41 - Odhad dovozu návykových látek a přípravků
Příloha č. 42 - Odhad výroby návykových látek, přípravků a prekursorů
125
VYHLÁŠKA
xx dne 31. xxxxxx 2006,
kterou xx xxxxxxx xxxxxxxxx xxxxxxxxx xxxxx xxxxxx x. 167/1998 Xx., x xxxxxxxxxx xxxxxxx x x změně xxxxxxxxx dalších xxxxxx, xx znění pozdějších xxxxxxxx
Xxxxxxxxxxxx xxxxxxxxxxxxx xxxxxxx xxxxx §44b xxxxxx x. 167/1998 Xx., x xxxxxxxxxx xxxxxxx x x změně xxxxxxxxx xxxxxxx xxxxxx, xx xxxxx xxxxxx x. 74/2006 Xx., (xxxx xxx "xxxxx"):
§1
(1) Xxxx xxxxxxxx stanoví xxxx tiskopisy formulářů:
x) v příloze č. 1 xxxxxx x xxxxxx xxxxxxxx x xxxxxxxxx x xxxxxxxxxx xxxxxxx x přípravky podle §8 xxxx. 7 xxxxxx,
x) x příloze č. 2 xxxxxx x xxxxxx povolení x xxxxxxxxx x xxxxxxxxxx - xxxxxxx xxxxx xxxxx xxxxxxxxxxxx xxxxxxxx Xxxxxxxxxx xxxxxxxxxxxx1),
x) x příloze č. 3 xxxxxx x xxxxxxxx xx xxxxxxx xxxxxxxxxxx x xxxxxxxxx osob x xxxxxxxx xxxxxx pracovišť, xxx jejichž xxxxxxx xx xxxxxxxxxx xxxxxxxx x xxxxxxxxx x xxxxxxxxxx látkami, xxxxxxxxx xx obsahujícími a xxxxxxxxxx xxxxx §5 xxxx. 7 x xxxxx §6 xxxx. 3 xxxxxx,
x) x příloze č. 4 žádost x xxxxx xxxxxxxx x xxxxxxxxx x xxxxxxxxxx xxxxxxx a xxxxxxxxx xxxxx §9 xxxx. 10 xxxxxx,
x) x příloze č. 5 xxxxxx o xxxxxxx xxxxxxxx x xxxxxxxxx x návykovými xxxxxxx x xxxxxxxxx xxxxx §8 odst. 11 xxxxxx,
f) x příloze č. 6 žádost o xxxxxxxxxx xxxxxxx pomocných xxxxx xxxxxxxxx v xxxxxxxxx 2 xxxxx xxxxx xxxxxxxxxxxx xxxxxxxx Xxxxxxxxxx společenství2),
x) x příloze č. 7 xxxxxx x xxxxxxxxxx xxxxxxx xxxxxxxxx látek xxxxxxxxx x xxxxxxxxxxx 2 x 3 xxxxx xxxxx xxxxxxxxxxxx xxxxxxxx Xxxxxxxxxx xxxxxxxxxxxx3),
x) x příloze č. 8 žádost x xxxxxxxxxx xxxxxxx xxxxxxxxx xxxxx xxxxxxxxx x kategorii 2 xxxxx xxxxx použitelného xxxxxxxx Evropských xxxxxxxxxxxx3),
x) v příloze č. 9 xxxxxx o xxxxxxxxxx xxxx xxxxxxxxxxx uvádět xx xxx xxxxxxx xxxxx xxxxxxx x xxxxxxxxx 2 xxxxx xxxxx xxxxxxxxxxxx xxxxxxxx Xxxxxxxxxx xxxxxxxxxxxx2),
x) x příloze č. 10 xxxxxx x vydání xxxxxxxx x xxxxxx návykových xxxxx a přípravků xxxxx §22 xxxx. 2 xxxxxx,
x) x příloze č. 11 žádost x vydání xxxxxxxx x xxxxxx xxxxxxxxxx xxxxx xxxxx xxxxxxxxxxxx xxxxxxxx Xxxxxxxxxx xxxxxxxxxxxx3),
x) x příloze č. 12 xxxxxx x xxxxxx xxxxxxxx x xxxxxx xxxxxxxxx xxxxx xxxxx xxxxx xxxxxxxxxxxx předpisu Xxxxxxxxxx xxxxxxxxxxxx3),
x) x příloze č. 13 xxxxxx x xxxxxx xxxxxxxx x xxxxxx pomocných xxxxx xxxxxxxxxxxxx postupem xxxxx přímo xxxxxxxxxxxx xxxxxxxx Xxxxxxxxxx xxxxxxxxxxxx3),
x) x příloze č. 14 xxxxxx o xxxxxx xxxxxxxx k xxxxxx xxxxxxxxxx xxxxx x xxxxxxxxx xxxxx §22 xxxx. 2 xxxxxx,
x) x příloze č. 15 xxxxxx x vydání xxxxxxxx x dovozu xxxxxxxxxx podle přímo xxxxxxxxxxxx xxxxxxxx Evropských xxxxxxxxxxxx3),
x) v příloze č. 16 žádost x xxxxxx povolení x xxxxxx xxxxxxxx podle §25 xxxx. 1 xxxxxx,
q) v příloze č. 17 xxxxxx x xxxxxx xxxxxxxx x xxxxxx makoviny xxxxx §25 odst. 1 xxxxxx,
r) v příloze č. 18 xxxxxxx hlášení x uskutečněném dovozu xxxxxxxxxx látek x xxxxxxxxx podle §26 xxxx. 1 xxxx. x) xxxxxx,
x) x příloze č. 19 hlášení x xxxxxxxxxxxx dovozu xxxxxxxxxx podle xxxxx xxxxxxxxxxxx xxxxxxxx Xxxxxxxxxx xxxxxxxxxxxx3),
x) x příloze č. 20 xxxxxxx xxxxxxx x xxxxxxxxxxxx xxxxxx xxxxxxxxxx xxxxx a xxxxxxxxx xxxxx §26 xxxx. 1 písm. x) zákona,
x) x příloze č. 21 xxxxxxx x xxxxxxxxxxxx xxxxxx xxxxxxxxxx podle xxxxx xxxxxxxxxxxx xxxxxxxx Xxxxxxxxxx xxxxxxxxxxxx3),
v) x příloze č. 22 xxxxxxx x xxxxxxxxxxxx xxxxxx xxxxxxxxx xxxxx xxxxx §28 xxxx. 1 xxxx. x) xxxxxx,
w) x příloze č. 23 čtvrtletní xxxxxxx x xxxxxxxxxxxx xxxxxx xxxxxxxx xxxxx §30 xxxxxx,
x) x příloze č. 24 xxxxxxxxxx xxxxxxx x uskutečněném xxxxxx xxxxxxxx xxxxx §30 zákona,
x) x příloze č. 25 souhrn xxxxxxx xxxxxxx x xxxxxxxxx x návykovými xxxxxxx, xxxxxxxxx a xxxxxxxxxx podle §26 xxxx. 1 xxxx. x) xxxxxx,
x) x příloze č. 26 přílohu x. I xxxxxxx xxxxxxx x xxxxxxxxx x xxxxxxxxxx xxxxxxx, xxxxxxxxx x xxxxxxxxxx - xxxxxx od xxxxxxxxxx v xxxxxxxx.
(2) Xxxx xxxxxxxx xxxx xxxxxxx xxxx xxxxxxxxx formulářů:
x) x příloze č. 27 přílohu x. XX xxxxxxx xxxxxxx o zacházení x xxxxxxxxxx xxxxxxx, xxxxxxxxx x xxxxxxxxxx - xxxxx xxxxxxxxxxx x tuzemsku,
x) x příloze č. 28 xxxxxxx x. III ročního xxxxxxx x xxxxxxxxx x xxxxxxxxxx látkami, xxxxxxxxx x xxxxxxxxxx - xxxxxx výroby,
x) x příloze č. 29 xxxxxxx x. XX xxxxxxx xxxxxxx x xxxxxxxxx s xxxxxxxxxx xxxxxxx, xxxxxxxxx x xxxxxxxxxx - výroba - xxxxx xxxxxxxxx xxxxxxx,
x) x příloze č. 30 xxxxxxx x. X xxxxxxx xxxxxxx x xxxxxxxxx s xxxxxxxxxx xxxxxxx, xxxxxxxxx x xxxxxxxxxx - xxxxxx - xxxxxx xxxxx zásob,
x) x příloze č. 31 xxxxx xxxxxxx xxxx provozujících xxxxxxx xxxxx §27 xxxxxx,
x) x příloze č. 32 xxxxxx ročního xxxxxxx o xxxxxx xxxxxxxxx xxxxx xxxxx §28 odst. 1 xxxx. x) xxxxxx,
x) x příloze č. 33 xxxxxxx x. I x xxxxxxx xxxxxxx x xxxxxx xxxxxxxxx xxxxx - xxxxxx xxxxxxxxxxxxxx xxxxxxxx xxx xxxxxxx xxxxx,
x) x příloze č. 34 souhrn xxxxxxx hlášení x xxxxxx xxxxxxxxx látek xxxxx §28 xxxx. 1 písm. x) xxxxxx,
x) x příloze č. 35 xxxxxxx x. X x xxxxxxx xxxxxxx o xxxxxx xxxxxxxxx xxxxx - xxxxxx xxxxxxxxx xxxxxxxxxx xxxxxxxx,
j) x příloze č. 36 xxxxxx xxxxxxx xxxxxxx x dovozu xxxxxxxxx látek xxxxxxxxx x xxxxxxxxx 2 xxxxx §28 odst. 1 písm. x) xxxxxx,
x) x příloze č. 37 xxxxxxx x. X x ročnímu xxxxxxx x dovozu xxxxxxxxx látek xxxxxxxxx x kategorii 2 - xxxxxx celkového xxxxxxxxxx množství,
l) x příloze č. 38 přílohu x. XX k xxxxxxx xxxxxxx x xxxxxx xxxxxxxxx xxxxx xxxxxxxxx x kategorii 2 - xxxxxx xxxxxxxxxxxxxx xxxxxxxx xxx xxxxxxx xxxxx,
m) x příloze č. 39 roční xxxxxxx Generálního xxxxxxxxxxx xxx o xxxxxxxxx xxxx xxxxxx x xxxxxx xxxxx §43 xxxx. 6 xxxx. x) xxxxxx,
x) x příloze č. 40 xxxxxxx Xxxxxxxxxxx ředitelství cel x osetých xxxxxxxx xxxxx setým x xxxxxxx x jejich xxxxxxxx xxxxx §43 xxxx. 6 xxxx. x) zákona,
x) x příloze č. 41 xxxxx xxxxxx xxxxxxxxxx látek x přípravků xxxxx §26 xxxx. 1 xxxx x) zákona,
x) x příloze č. 42 xxxxx xxxxxx xxxxxxxxxx xxxxx, xxxxxxxxx x xxxxxxxxxx podle §26 xxxx. 1 písm. x) xxxxxx.
§2
Účinnost
Xxxx xxxxxxxx xxxxxx xxxxxxxxx dnem xxxxxx xxxxxxxxx.
Xxxxxxx:
XXXx. Rath v. x.
Xxxxxxx x. 1 x vyhlášce x. 125/2006 Xx.
XXXXXX X XXXXXX XXXXXXXX
x xxxxxxxxx x xxxxxxxxxx xxxxxxx x xxxxxxxxx
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Xxxxxx č. 5 xxxxxxx
XXXXXX X XXXXXX XXXXXXXX
x xxxxxxxxx s xxxxxxxxxx látkami x xxxxxxxxx
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XX:
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&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; |
X. Xxxxxxxxx
&xxxx;
Xxxxx xxxxxxx xxxxxx x. 167/1998 Xx.
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Xxxxx xxxxxxxx látky xxxx xxxxxxxxx (xxxxxxxx xxxxx x přípravky x následujícím xxxxxx: XX, PL)
- x xxxxxxxxxx xxxxx xxxxxxxx xxxxxxxxxxx xxxxxxxxxx xxxxx (XXX) x xxxxxx xxxxxx podle xxxxxx xxxxxx, xxxxxx xxxxx xxxx, xxxxxxx, xxxxxx x xxxxx x xxxxxx xxxx;
- x XXXX xxxxxxxx pouze xxxxxxxxxxxx xxxxx včetně xxxx x xxxxxxxxx xxxxxx
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Xxxxxxx xxxxxxxxx xxxxxxx
(xxxx. xxxxxxxxx xxxxxxxxx zvířat, xxxxxxxxxx xxxxxxx, xxxxxxxxxx xxxxxxx, terapie x xxxxxx xxxxxx, xxxxxxxxxxx xxxxxx apod.)
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Strana č. 6 xxxxxxx
XXXXXX X XXXXXX XXXXXXXX
x xxxxxxxxx x xxxxxxxxxx xxxxxxx x xxxxxxxxx
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X. Výzkum
Číslo xxxxxxx xxxxxx x. 167/1998 Xx.
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Xxxxx xxxxxxxx xxxxx nebo xxxxxxxxx (xxxxxxxx xxxxx x xxxxxxxxx x xxxxxxxxxxxx xxxxxx: XX, XX)
- x návykových látek xxxxxxxx xxxxxxxxxxx nechráněný xxxxx (INN) x xxxxxx xxxxxx podle xxxxxx zákona, xxxxxx xxxxx solí, izomerů, xxxxxx x éterů x jejich xxxx;
- x XXXX xxxxxxxx xxxxx xxxxxxxxxxxx xxxxx xxxxxx xxxx x xxxxxxxxx balení
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Xxxxxx č. 7 xxxxxxx
XXXXXX X VYDÁNÍ XXXXXXXX
x xxxxxxxxx x xxxxxxxxxx xxxxxxx x xxxxxxxxx
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&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; |
X. Xxxxxxxxxx
&xxxx;
Xxxxx přílohy xxxxxx x. 167/1998 Xx.
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Xxxxx xxxxxxxx xxxxx xxxx xxxxxxxxx (xxxxxxxx xxxxx x xxxxxxxxx x následujícím xxxxxx: XX, XX)
- x xxxxxxxxxx xxxxx uvádějte xxxxxxxxxxx xxxxxxxxxx xxxxx (XXX) x xxxxxx xxxxxx xxxxx xxxxxx xxxxxx, xxxxxx xxxxx xxxx, izomerů, xxxxxx x xxxxx x xxxxxx solí;
- x XXXX xxxxxxxx xxxxx xxxxxxxxxxxx xxxxx včetně xxxx x xxxxxxxxx xxxxxx
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Xxxxxxx xxxxxxxxx xxxxxxx (xxxx. xxxxxxxxx, xxxxxxxxxxx, xxxxxxxxxxx xxxx.)
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Xxxxx xxxxxxxxxx (xxxxxx xxxxxx xxxxxx XXX)
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Xxxxxx x. 8 xxxxxxx
XXXXXX O VYDÁNÍ XXXXXXXX
x zacházení s xxxxxxxxxx xxxxxxx x xxxxxxxxx
&xxxx;
XX:
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X. Xxxx
&xxxx;
Xxxxx xxxxxxx xxxxxx č. 167/1998 Xx.
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Xxxxx návykové látky xxxx přípravku (xxxxxxxx xxxxx x xxxxxxxxx x xxxxxxxxxxxx xxxxxx: XX, XX)
- x xxxxxxxxxx xxxxx uvádějte xxxxxxxxxxx nechráněný název (XXX) v xxxxxx xxxxxx xxxxx příloh xxxxxx, včetně xxxxx xxxx, xxxxxxx, xxxxxx x xxxxx x xxxxxx solí;
- x XXXX xxxxxxxx pouze xxxxxxxxxxxx názvy xxxxxx xxxx x xxxxxxxxx xxxxxx
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Xxxxxxx konkrétní xxxxxxx(x)
(xxxxx xxxxxx xxxxxxx xxx xxxxxxx X až X xxxxxxx x xxxxxx se xxxxxxxxx x xxxxxxxxxx xxxxxxx xxxx xxxxxxxxx xxxxx §3 xxxxxx č. 167/1998 Xx.)
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Xxxxxx x. 9 žádosti
ŽÁDOST O XXXXXX POVOLENÍ
k zacházení x xxxxxxxxxx látkami x přípravky
III. Xxxxxxx xxxx x vydání xxxxxxxx x zacházení x návykovými látkami x xxxxxxxxx xx xxxx ...........xxx (maximálně 5 let xxxxx §8 xxxx. 3 xxxxxx x. 167/1998 Xx.)
XX. Fyzické xxxxx xxxxxxxxx xxxxxx xxxxxx xxxxxxxx:
(xxxx. dle obchodního xxxxxxxxx)
&xxxx;
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Xxxxx, příjmení, xxxxx:
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Xxxxxxx:
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Xxxxxx:
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Xxxxxx:
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1.
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2
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3.
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4.
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XX. Xxxxxxxxx osoba:
Jméno, xxxxxxxx, xxxxx:
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Xxxxxx:
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Xxxxxx:
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Xxxxxx xxxxx xxxxxxxx xxxxxx xxxxxx XXX:
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Xxxxxxx: Xxxxx:
Xxxxxxxx, x které xxxxxxxx, x xxxxxxxxxx xxxxxxx proškrtněte souvislou xxxxx.
Xxxxxx x. 10 xxxxxxx
Xxxxxxx x xxxxxxx x xxxxxx xxxxxxxx x xxxxxxxxx x xxxxxxxxxx xxxxxxx x xxxxxxxxx
Xxxxxxx přikládá xxxxxxxxx xxxxxxx (xxxxxxxx, xxxxxxxxx xxxx úředně xxxxxxx xxxxx).
&xxxx;
Xxxxx xxxxxxx
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Xxxxx
xxxxx
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Xxxxxxxxxx dokládající xxxxxxxx x xxxxxxxx x léčivy
(§3 odst. 1 zákona x. 79/1997 Xx.)
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Xxxxxxxxx x xxxxxxx xxxxxxxx k xxxxxx xxxxxxxxxxx xxxxxxx x preventivní xxxxxxxx
(xxxxx x. 381/1991 Xx.)
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Xxxxx x Rejstříku xxxxxx (xx xxxxxx 3 xxxxxx) všech osob xxxxxxxxxxx jednat xx xxxxxxxx
(§8 odst. 5 xxxxxx x. 167/1998 Xx)
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Xxxxxx/Xxxxxxxxxx x xxxxxxxx x xxxxxxxxx
(xxxx. živnostenský xxxx, xxxxxxxx listina)
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Doklad/Rozhodnutí x totožnosti xxxxxxxx, xxxxx není xxxxxx x obchodním rejstříku
(např. xxxxxxxxx xxxxxxx včetně xxxxxxxxxxx xxxxxxx xxxxxxxxxx xxxxx, xxxxxx o xxxxxxxxx XX)
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Xxxxxxx
(xxxx. o xxxxxxxx xxxxxxxxxx prostor, x xxxxxxxxx xxxxxxx xxxxxxxxxxx činnosti)
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Technologický xxxxxxx xxxxxx
(§8 odst. 7 xxxxxx x. 1671998 Xx.)
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Xxxxxx x ustanovení xxxxxxxxx xxxxx
(§8 xxxx. 6 xxxxxx x. 1671998 Xx.)
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Xxxxx x Xxxxxxxxx xxxxxx (ne xxxxxx 3 měsíců) xxxxxxxxx osoby
(§9 xxxx. 3 a §17 xxxxxx x. 167/1998 Xx.
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Xxxxxxxx xxxxxxx o xxxxxxxxx způsobilosti (xx xxxxxx 3 xxxxxx) xxxxxxxxx osoby
(§9 xxxx. 4 x §18 xxxxxx x. 167/1998 Xx.)
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Xxxxxx x vzdělání xxxxxxxxx xxxxx
(§9 odst. 3 x §19 xxxx. 1 xxxxxx x. 167/1998 Xx.
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Xxxxxxxxxx xxxxx potřebné xxxxxxx xxxx xxxxxxxxx
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&xxxx; | &xxxx; |
Xxxxxxx x. 2 x xxxxxxxx x. 125/2006 Xx.
XXXXXX X XXXXXX POVOLENÍ
k xxxxxxxxx x prekursory - XXXXXXX
&xxxx;
Xxxxx příloh x xxxxxxx:
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Xxxxx xxxxx xxxxxx xxxxxx xxxxxx:
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Xxxxx xxxxx xxxxxx xxxxxxxxx xxxxxx:
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Xxxxx (xxxxx x xxxx):*)
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Xxxxxxx xxxx o xxxxxx xxxxxxxx x xxxxxxxxx x xxxxxxxxxx xxxxx:
- Xxxxxxxx Xxxxxxxxxx xxxxxxxxxx x Rady (XX) č. 273/2004,
- Xxxxxxxx Rady (XX) č. 111/2005 x
- Xxxxxxxx Xxxxxx (XX) č. 1277/2005
X. Žadatel:
Název/jméno:
(název xxxxxxxxx xxxxx / obchodní xxxxx / jméno x xxxxxxxx fyzické xxxxx) xxxxxx
xxxxxxxxxxxx xxxxxxx
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&xxxx;
Xxxxxx xxxxx:
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&xxxx;
Xxxxxx xxxxxx XXX:
(xxxxx xxxxxxxxx xxxxx / xxxxx xxxxxxxx pobytu xxxxxxx xxxxx)
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&xxxx;
Xxxxxx pro xxxxxxxxxx xxxxxx XXX:
xxxxx xx xxxxxxx xx xxxx xxxxxxx xxxxxx
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&xxxx;
Xxxxxxxxxxxxx xxxxx (XX):
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Xxx:
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*) V xxxxxxx xxxxxx xxxxxxxxx xxxxxxxx xxxxxxxxx xxxxxxxx xxxxxx jejich xxxxx x cenu.
Strana x. 1 žádosti
ŽÁDOST X XXXXXX POVOLENÍ
k zacházení x xxxxxxxxxx - XXXXXXX
&xxxx;
XX:
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&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; |
&xxxx;
Xxx XX
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Xxxxx prekursoru xxxxx xxxxxxx I xxxxxxxx XXX (ES) č. 273/2004 a xxxxxxx xxxxxxxx Xxxx (XX) č. 111/2005 x xxxxxx xxxxxx
- xxxxxx xxxxx xxxx x xxxxxxxxxxxxxxxxxx xxxxx xxxxxxxxxx uvedených x xxxxxxx I xxxxxxxx XXX (XX) č. 273/2004 x xxxxxxx xxxxxxxx Xxxx (XX) č. 111/2005 x českém xxxxxx;
- x xxxxxxx xxxxx xxxx přírodního xxxxxxxx uveďte x xxxx xxxxx (xx. 5 odst. 1 xxxx. h) xxxxxxxx Xxxxxx (ES) č. 1277/2005);
- x XXXX xxxxxxxx xxxxx registrované xxxxx xxxxxx xxxx x xxxxxxxxx xxxxxx.
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Xxxxxxxx xxxxx xxxxxxxx (např. XXX (XX) č. 273/2004 x xxxxx xxxxxxxx Xxxx (XX) č. 111/2005
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&xxxx;
Xxxxxxxxx xxxxxxxx xxxxxxxxxx činnost, xxxxxx xxxxxxxxx, xxxxxxxxxxx, xxxxxxxxxxx xxxx.)
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Xxxxxx xxxxxxxxxx, xxx xxxx xxxxxxx xxxxxxxxxx
(xxxxxx xxxxxx xxxxxx XXX)
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Xxxxxx x..........xxxxxxx
XXXXXX X VYDÁNÍ XXXXXXXX
x xxxxxxxxx x xxxxxxxxxx - XXXXXXX
XX. Xxxxxxx xxxx x xxxxxx xxxxxxxx x xxxxxxxxx s xxxxxxxxxx - XXXXXXX
xx xxxx ....... xxx (maximálně 3 xxxx xxxxx xx. 3 xxxx. 5 Xxxxxxxx Xxxxxxxxxx xxxxxxxxxx x Xxxx (XX) č. 273/2004 a xxxxx xx. 9 Xxxxxxxx Rady (XX) č. 111/2005)
XXX. Xxxxxxx xxxxx xxxxxxxxx jednat xxxxxx xxxxxxxx:
(xxxx. xxx xxxxxxxxxx xxxxxxxxx)
&xxxx;
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Xxxxx, příjmení, xxxxx:
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Xxxxxxx:
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Xxxxxx:
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Xxxxxx:
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1.
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2
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3.
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4.
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XX. Odpovědná xxxxx:
&xxxx;
Xxxxx, xxxxxxxx, titul:
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Funkce:
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podpis:
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Adresa xxxxx xxxxxxxx pobytu včetně XXX:
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X-xxxx:
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Xxx:
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Xxxxxxx: Xxxxx:
Xxxxxxxx součástí xxxxxxx xx též xxxxxxxxxx xxxxxxxx o xxxxxxxxx xxxxxxxxxx xxxxx xxxxxxxxxxxxx xxxxxxxx xxxxxxxxxx xxxxx xx. 5 xxxx. 1 xxxx. x) xxxxxxxx Xxxxxx (XX) č. 1277/2005.
Upozornění:
Po xxxxxxxx xxxxxxxxx XXXXXXX (tj. xxxxxxxx k xxxxxxxxx x xxxxxxxxxx) je xxxxxxx xxxxxxx podle xx. 10 nařízení Xxxxxx (XX) č. 1277/2005 xxxxxx xxxx xxxxxxxx Xxxxxxxxxxxx xxxxxxxxxxxxx.
Xxxxxxxxxx kolonky xxxxxxxxxxx xxxxxxxxx xxxxx.
Xxxxxx x. ............xxxxxxx
Xxxxxxx x xxxxxxx x vydání xxxxxxxx k zacházení x xxxxxxxxxx - XXXXXXX
Xxxxxxx přikládá xxxxxxxxx xxxxxxx (xxxxxxxx, xxxxxxxxx xxxx úředně xxxxxxx xxxxx).
&xxxx;
Xxxxx xxxxxxx
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Xxxxx
xxxxx
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&xxxx;
Xxxxxxxxxx dokládající xxxxxxxx x xxxxxxxxx x xxxxxx
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&xxxx;
Xxxxx x Xxxxxxxxx xxxxxx (xx xxxxxx 3 xxxxxx) xxxxx xxxx xxxxxxxxxxx xxxxxx za xxxxxxxx
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&xxxx;
Xxxxx x xxxxxxxxxx xxxxxxxxx
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&xxxx;
Xxxxxx/Xxxxxxxxxx x xxxxxxxx x xxxxxxxxx
(xxxx. xxxxxxxxxxxx list, xxxxxxxx listina)
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Doklad/Rozhodnutí x xxxxxxxxxx xxxxxxxx. xxxxx xxxx zapsán x xxxxxxxxx xxxxxxxxx
(xxxx. zřizovací xxxxxxx xxxxxx jmenovacího xxxxxxx statutární xxxxx. xxxxxx x xxxxxxxxx XX)
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Xxxxxxxxxx x xxxxxxxxx xxxxxxxxxx proti xxxxxxxxxxxxx xxxxxxxx prekursorů
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Smlouva
(např. x xxxxxxxx skladových prostor)
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Technologický xxxxxxx xxxxxx
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Xxxxxx x xxxxxxxxxx odpovědné osoby
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Výpis x Xxxxxxxxx xxxxxx (xx xxxxxx 3 xxxxxx) xxxxxxxxx xxxxx
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&xxxx;
Xxxxxxxx xxxxxxx x zdravotní xxxxxxxxxxxx (xx xxxxxx 3 xxxxxx) odpovědné xxxxx
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&xxxx;
Xxxxxx x xxxxxxxx xxxxxxxxx osoby
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Eventuálně xxxxx xxxxxxxx přílohy xxxx xxxxxxxxx
|
&xxxx; |
&xxxx; | &xxxx; |
Xxxxxxx č. 3 x xxxxxxxx x. 125/2006 Sb.
ŽÁDOST X XXXXXXXX XX XXXXXXX
xxxxxxxxxxx x fyzických xxxx x xxxxxxxx xxxxxx xxxxxxxxx, pro xxxxxxx xxxxxxx xx nevyžaduje xxxxxxxx k xxxxxxxxx x návykovými xxxxxxx, xxxxxxxxx xx xxxxxxxxxxxx x xxxxxxxxxx
&xxxx;
Xxxxx xxxxxx x xxxxxxx:
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&xxxx;
Xxxxx xxxxx xxxxxx xxxxxx celkem:
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Počet xxxxx xxxxxx tiskopisu xxxxxx:
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&xxxx; | &xxxx; |
Xxxxxxx xxxx o xxxxxxxx xx xxxxxxx xxxxxxxxxxx x fyzických xxxx s xxxxxxxx xxxxxx xxxxxxxxx, xxx xxxxxxx xxxxxxx xx xxxxxxxxxx xxxxxxxx k xxxxxxxxx s návykovými xxxxxxx, xxxxxxxxx xx xxxxxxxxxxxx a xxxxxxxxxx xxxxx §5 xxxx. 7 x §6 xxxx. 3 xxxxxx x. 167/1998 Xx.
X. Xxxxxxx:
&xxxx;
Xxxxx/xxxxx xxxxxxxx:
(xxxxx xxxxxxxxx xxxxx / xxxxx x xxxxxxxx fyzické xxxxx)
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx xxxxxxxx xxxxxx XXX:
(xxxxx xxxxxxxxx xxxxx / xxxxx xxxxxxxx xxxxxx xxxxxxx xxxxx)
|
&xxxx; | ||||||||
&xxxx;
Xxxxxxxxxx:
|
&xxxx; | ||||||||
&xxxx;
Xxxxx xxxxxxxxxx:
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx xxxxxxxxxx včetně XXX:
|
&xxxx; | ||||||||
&xxxx;
Xxxxxxxxxxxxx xxxxx (XX):
|
&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | |
&xxxx;
Xxxxxxx:
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&xxxx;
Xxx:
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&xxxx;
X-xxxx:
|
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&xxxx; | &xxxx; | &xxxx; | |||||||
&xxxx; | &xxxx; | &xxxx; |
Xxxxxx x. 1 xxxxxxx
XXXXXX X XXXXXXXX DO XXXXXXX
&xxxx;
XX:
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&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; |
&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; |
XX. Xxxxxxxxxx xx xxxx xxxxxxx xxxxxxxxx:
X. Xxxxxx (xxxx. xxx xxxxxx, xxxxxx, odběru, xxxxxxxxx, apod.)
Číslo přílohy xxxxxx x. 167/1998 Xx.
|
&xxxx;
Xxxxx návykové xxxxx, xxxxxxxxx, xxxxxxxxxx (návykové xxxxx, xxxxxxxxx a xxxxxxxxxx x xxxxxxxxxxxx xxxxxx: XX, PL, xxxxxxxxxx)
- x xxxxxxxxxx xxxxx uvádějte xxxxxxxxxxx xxxxxxxxxx název (XXX) x xxxxxx xxxxxx xxxxx příloh zákona, xxxxxx xxxxx xxxx, xxxxxxx, esterů a xxxxx x xxxxxx xxxx;
- u xxxxxxxxxx (xxxxx xxxxxxxxx 1) xxxxxxxx xxxxx podle xxxxxxx X nařízení XXX (XX) č. 273/2004 x xxxxxx xxxxxx:
- x HVLP xxxxxxxx xxxxx xxxxxxxxxxxx xxxxx xxxxxx síly x xxxxxxxxx balení.
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Strana č. 2 žádosti
ŽÁDOST X XXXXXXXX XX XXXXXXX
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X. Xxxxxxxxxxx příprava
Číslo xxxxxxx xxxxxx x. 167/1998 Xx.
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Xxxxx návykové xxxxx, xxxxxxxxx, xxxxxxxxxx (návykové xxxxx, přípravky, a xxxxxxxxxx x xxxxxxxxxxxx xxxxxx: XX, XX, xxxxxxxxxx)
- x návykových xxxxx xxxxxxxx mezinárodní xxxxxxxxxx xxxxx (XXX) x xxxxxx xxxxxx xxxxx xxxxxx xxxxxx, xxxxxx xxxxx solí, xxxxxxx, esterů x xxxxx a xxxxxx xxxx;
- u prekursorů (xxxxx xxxxxxxxx 1) xxxxxxxx názvy xxxxx xxxxxxx X xxxxxxxx XXX (XX) č. 273/2004 x xxxxxx jazyce;
- x HVLP xxxxxxxx xxxxx registrované xxxxx xxxxxx síly x xxxxxxxxx balení.
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Množství předpokládané xxxxxxxxxxx přípravy za xxxxxxxxxx rok xxxx xxxx část (xxxxx x gramech, xxxxxxxxxxx)
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Xxxxx xxxxxxxxxxx přípravy (uveďte xxxxxx, XXX)
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Xxxxxx x. 3 xxxxxxx
XXXXXX X XXXXXXXX XX SEZNAMU
IČ:
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C. Xxxxxxxxxx
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Xxxxx xxxxxxx zákona x. 167/1998 Xx.
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Xxxxx xxxxxxxx látky, xxxxxxxxx, xxxxxxxxxx (návykové xxxxx, xxxxxxxxx, a prekursory x následujícím xxxxxx: XX, XX, xxxxxxxxxx)
- x xxxxxxxxxx xxxxx xxxxxxxx mezinárodní xxxxxxxxxx xxxxx (INN) v xxxxxx xxxxxx podle xxxxxx zákona, xxxxxx xxxxx xxxx, izomerů, xxxxxx x éterů x jejich xxxx;
- x xxxxxxxxxx (xxxxx xxxxxxxxx 1) uvádějte xxxxx xxxxx xxxxxxx X xxxxxxxx XXX (XX) č. 273/2004 v xxxxxx xxxxxx;
- x XXXX xxxxxxxx pouze xxxxxxxxxxxx názvy xxxxxx xxxx a xxxxxxxxx xxxxxx.
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Xxxxxx x. 4 xxxxxxx
XXXXXX X XXXXXXXX XX XXXXXXX
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X. Výdej (xxxx. xxx prodeji, xxxxxxxx, xxxxxx xxxx.)
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Xxxxx xxxxxxx zákona č. 167/1998 Xx.
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Xxxxx xxxxxxxx xxxxx, přípravku, xxxxxxxxxx (xxxxxxxx xxxxx, přípravky x xxxxxxxxxx x xxxxxxxxxxxx pořadí: OL, XX, prekursory)
- x xxxxxxxxxx xxxxx xxxxxxxx xxxxxxxxxxx nechráněný xxxxx (XXX) x xxxxxx xxxxxx xxxxx xxxxxx xxxxxx, xxxxxx xxxxx xxxx, izomerů, xxxxxx x xxxxx x xxxxxx xxxx;
- x xxxxxxxxxx (xxxxx kategorie 1) xxxxxxxx xxxxx xxxxx přílohy X xxxxxxxx XXX (ES) č. 273/2004 x xxxxxx xxxxxx;
- x HVLP xxxxxxxx xxxxx xxxxxxxxxxxx xxxxx xxxxxx síly x velikosti xxxxxx.
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Xxxxxx x. 5 xxxxxxx
XXXXXX X XXXXXXXX XX XXXXXXX
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X. Xxxxxx, xxxxxxxxx
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Xxxxx xxxxxxx zákona x. 167/1998 Xx.
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Xxxxx xxxxxxxx xxxxx, xxxxxxxxx, xxxxxxxxxx (xxxxxxxx látky, přípravky x xxxxxxxxxx x xxxxxxxxxxxx xxxxxx: XX, XX, prekursory)
- x xxxxxxxxxx xxxxx xxxxxxxx xxxxxxxxxxx nechráněný xxxxx (XXX) x xxxxxx xxxxxx podle xxxxxx xxxxxx, xxxxxx xxxxx xxxx, izomerů, esterů x xxxxx a xxxxxx xxxx;
- x xxxxxxxxxx (látky xxxxxxxxx 1) xxxxxxxx názvy xxxxx přílohy X xxxxxxxx EPR (XX) č. 273/2004 v českém xxxxxx;
- x HVLP xxxxxxxx pouze xxxxxxxxxxxx xxxxx včetně xxxx x xxxxxxxxx balení.
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Popište xxxxxxxxx xxxxxxx
(xxxx. experimentální xxxxxx, xxxxxxxxxxxxxx xxxxxxx, xxxxxxxxx xxxxxxxxx zvířat, xxxxxxxxxx xxxxxxx, expertizní xxxxxxx, soudně xxxxxxxxxxxxx xxxxxxx xxxx.)
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Xxxxxx x. 6 xxxxxxx
XXXXXX X XXXXXXXX DO XXXXXXX
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X. Xxxx
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Xxxxx xxxxxxxx xxxxx, xxxxxxxxx, xxxxxxxxxx (návykové xxxxx, xxxxxxxxx a xxxxxxxxxx x xxxxxxxxxxxx xxxxxx: XX, PL, prekursory)
- x xxxxxxxxxx xxxxx xxxxxxxx xxxxxxxxxxx xxxxxxxxxx xxxxx (XXX) x xxxxxx xxxxxx xxxxx xxxxxx xxxxxx, xxxxxx xxxxx xxxx, xxxxxxx, xxxxxx a xxxxx x jejich xxxx;
- x xxxxxxxxxx (látky xxxxxxxxx 1) xxxxxxxx xxxxx xxxxx přílohy X xxxxxxxx XXX (XX) č. 273/2004 x xxxxxx xxxxxx;
- u XXXX xxxxxxxx xxxxx xxxxxxxxxxxx xxxxx xxxxxx xxxx x xxxxxxxxx xxxxxx.
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Xxxxxxx konkrétní xxxxxxxx (xxxxx nejsou xxxxxxx xxx písmeny X xx E žádosti x týkají xx xxxxxxxxx x xxxxxxxxxx xxxxxxx, přípravky a xxxxxxxxxx podle §3 x §3x zákona x. 167/1998 Xx.
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Xxxxx xxxxxxxx
(xxxxxx xxxxxx včetně XXX, x to xxxxx x případě, xx adresa xxxxx xxxxxxxx xx xxxxxxxx xx adresy uvedené x xxxxxx I xxxxxxx jako xxxxxx xxxxxxxxxx)
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Xxxxxx x. 7 xxxxxxx
XXXXXX X XXXXXXXX XX XXXXXXX
XXX. Xxxxxxx xxxxx xxxxxxxxx xxxxxx xxxxxx xxxxxxxx:
(xxxx. xxx xxxxxxx, obchodního rejstříku)
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Jméno, xxxxxxxx, titul:
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IV. Xxxxxxxxx xxxxx xxx Xxxxxxxxxxxx xxxxxxxxxxxxx - xxxxx Xxxxxxxxxxx xxxxxxxx x xxxxxxxxxxxxxx xxxxx xxxxxxxxx xx xxxxxxxxx x xxxxxxxxxx xxxxxxx, přípravky x xxxxxxxxxx xx xxxxxxxxxx:
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Xxxxxxx: Xxxxx:
Xxxxxxxx, x xxxxx xxxxxxxx, x nevyplněné kolonky xxxxxxxxxxx xxxxxxxxx čarou.
Strana x. 8 xxxxxxx
Xxxxxxx x xxxxxxx x xxxxxxxx xx xxxxxxx xxxxxxxxxxx x xxxxxxxxx xxxx x xxxxxxxx xxxxxx xxxxxxxxx, xxx xxxxxxx činnost xx xxxxxxxxxx povolení x xxxxxxxxx s xxxxxxxxxx xxxxxxx, přípravky je xxxxxxxxxxxx x prekursory
Žadatel xxxxxxxx xxxxxxxxx xxxxxxx (xxxxxxxx, xxxxxxxxx xxxx xxxxxx xxxxxxx kopie).
Název xxxxxxx
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Xxxxxx/Xxxxxxxxxx o xxxxxxxxxx xxxxxxxx, xxxxx není xxxxxx x xxxxxxxxx xxxxxxxxx (např. xxxxxxxxx xxxxxxx xxxxxxxxxx xxxxxx xxxxxxxxxxx xxxxxxx xxxxxxxxxx xxxxx, xxxxxx xxxxxxxxxx, xxxxxx x xxxxxxxxx XX)
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Xxxxxxxxxxxxx předpis xxxxxxxxxxx xxxxxxxx, xxxxx xx xxxxxxxxxx xxxx xxxxxxx xxxxxxxxxxx přípravou x xxxxx xxxx. xxxxxxx
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Xxxxxxx x. 4 x vyhlášce x. 125/2006 Xx.
XXXXXX X XXXXX XXXXXXXX
x xxxxxxxxx x návykovými xxxxxxx x přípravky
(pouze xxxxx xxxxxxxxx osoby)
Počet xxxxxx x žádosti
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Žadatel xxxx o xxxxx xxxxxxxx x xxxxxxxxx x xxxxxxxxxx látkami x přípravky xxxxx §9 xxxx. 10 xxxxxx x. 167/1998 Xx.
X. Žadatel:
Název/jméno:
(název xxxxxxxxx xxxxx / xxxxxxxx xxxxx / jméno x příjmení xxxxxxx xxxxx) xxxxxx
xxxxxxxxxxxx xxxxxxx
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Xxxxxx xxxxxx XXX:
(xxxxx xxxxxxxxx xxxxx / xxxxx xxxxxxxx xxxxxx xxxxxxx osoby)
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Adresa xxx xxxxxxxxxx včetně XXX:
xxxxx xx xxxxxxx xx xxxx xxxxxxx adresy
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Identifikační xxxxx (IČ):
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Telefon:
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II. Xxxxxxx xxxxx xxxxxxxxx xxxxxx xxxxxx žadatele:
(xxxx. xxx obchodního rejstříku)
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Jméno, xxxxxxxx, xxxxx:
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XXX. Xxxx xxxxxxxxxx odpovědná osoba:
Jméno, xxxxxxxx, xxxxx:
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Xxxxxxx: Xxxxx:
Xxxxxxxxxx xxxxxxx xxxxxxxxxxx souvislou xxxxx.
Xxxxxxx x xxxxxxx x xxxxx xxxxxxxx x xxxxxxxxx
(xxxxx xxxxx xxxxxxxxx xxxxx)
Xxxxxxx xxxx xxxxxxxx xxxxxxxxxxx xxxxxxx (xxxxxxxx, xxxxxxxxx xxxx xxxxxx xxxxxxx kopie).
Název xxxxxxx
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Xxxxxx x ustanovení xxxxxxxxx xxxxx
(§8 odst. 6 xxxxxx x. 167/1998 Xx.)
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Xxxxx x Xxxxxxxxx xxxxxx (ne xxxxxx 3 měsíců) xxxxxxxxx xxxxx
(§9 xxxx. 3 x §17 zákona x. 167/1998 Xx.)
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Xxxxxxxx xxxxxxx x xxxxxxxxx xxxxxxxxxxxx (ne xxxxxx 3 xxxxxx) xxxxxxxxx xxxxx
(§9 xxxx. 4 x §18 xxxxxx x. 167/1998 Xx.)
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Xxxxxx x vzdělání xxxxxxxxx xxxxx
(§9 xxxx. 3 x §19 xxxx. 1 xxxxxx x. 167/1998 Xx.)
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Xxxxxxx x. 5 x xxxxxxxx x. 125/2006 Xx.
XXXXXX O XXXXXXX XXXXXXXX
x zacházení x xxxxxxxxxx xxxxxxx x xxxxxxxxx
Xxxxxxx žádá x xxxxxxx povolení x zacházení xxxxx §8 xxxx. 11 xxxxxx x. 167/1998 Xx.
X. Xxxxxxx:
&xxxx;
Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / obchodní xxxxx / jméno x xxxxxxxx xxxxxxx xxxxx) xxxxxx
xxxxxxxxxxxx xxxxxxx
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Identifikační číslo (XX):
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XX. Xxxxx x xxxxx ukončení xxxxxxxx:
(x xxxxxxx xxxxxxxxxx xxxxx xxxxxx x příloze)
III. Xxxxxxxxxxx je uložena x:
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Xxxxx xxxxxxxxx xxxxx / obchodní xxxxx / xxxxx x xxxxxxxx xxxxxxx xxxxx:
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Xxxxx xxxxxxxxx xxxxx / xxxxx xxxxxxxx xxxxxx xxxxxxx xxxxx xxxxxx XXX:
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XX. Fyzické xxxxx xxxxxxxxx jednat xxxxxx xxxxxxxx:
(xxxx. dle xxxxxxxxxx xxxxxxxxx)
&xxxx;
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X. Xx xxxxxxx xxxxxxxxxxx x xxxx dostupnost xxxxxxxx:
&xxxx;
Xxxxx, xxxxxxxx, xxxxx:
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Xxxxxx xxxxx xxxxxxxx xxxxxx xxxxxx XXX:
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Xxxxxxx: Xxxxx:
Xxxxxxxxxx xxxxxxx xxxxxxxxxxx xxxxxxxxx xxxxx.
Xxxxxxx x xxxxxxx x xxxxxxx xxxxxxxx x zacházení x xxxxxxxxxx látkami x xxxxxxxxx
Xxxxxxx přikládá příslušné xxxxxxx (originál, xxxxxxxxx xxxx xxxxxx xxxxxxx xxxxx).
&xxxx;
Xxxxx xxxxxxx
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Xxxxx
xxxxx
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Xxxxx xx xxxxx do xxxxxxxxxx xxxxxxxxx (x xxxxxxxxxx xxxxxxx xxxxxx xxxxxx)
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Xxxxxxxxxx xxxxxxxxxxxxxx xxxxx x xxxxxxx xxxxxxxxxxxxxx oprávnění
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Žádost xxxxxxxxxxx o zrušení xxxxxxxxxxxxxx xxxxxxxxx (s xxxxxxxxxx xxxxxxx xxxxxxx xxxxxxxxxxxxx úřadem)
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Mimořádné hlášení (§26 xxxx. 4 xxxxxx č. 167/1998 Xx.) - xx 30 dnů xx xxxxxxxx xxxxxxxx
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&xxxx;
Xxxxxxxx x xxxxxxx a xxxxxxxx xxxxxxxxxxx x xxxxxxxx x xxxxxxx
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&xxxx;
Xxxxxxxxxx xxxxx xxxxxxxx xxxxxxx xxxx xxxxxxxxx
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&xxxx; |
&xxxx; | &xxxx; |
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Xxxxxxx xxxx x xxxxxxxxxx výrobce xxxxxxxxx xxxxx xxxxxxxxx x xxxxxxxxx 2 xxxxxxx X xxxxxxxx Xxxxxxxxxx xxxxxxxxxx a Xxxx (XX) č. 273/2004
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|
Název pomocné xxxxx xxxxx xxxxxxx xxxxxxxx Rady (ES) č. 111/2005
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XX. Odpovědná xxxxx:
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Xxxxxxx: Datum:
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Xxxxxx x xxxxxxxxxx xx podává xx xxxx xxxxxxxxxxxx!
Xxxxxxxxxx xxxxxxx proškrtněte souvislou xxxxx.
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|
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|
|
Eventuálně xxxxx potřebné xxxxxxx xxxx neuvedené
|
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Xxxxxxx x. 8 x xxxxxxxx x. 125/2006 Xx.
XXXXXX X XXXXXXXXXX
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Xxxxx příloh x xxxxxxx:
|
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Xxxxx xxxxx těchto xxxxxx xxxxxx:
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|
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Xxxxxx forma:
|
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XX. Xxxxxxx xxxxx (xxxxxxxxxxx):
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Xxx KN
|
Název pomocné xxxxx podle xxxxxxx X xxxxxxxx Xxxx (XX) č. 111/2005
|
Provozovny, kde xxxx xxxxxxxxxxxx xxxxxxx xxxxxxxxxx (xxxxxx adresu xxxxxx XXX)
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XX. Xxxxxxxxx xxxxx:
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Xxxxxx xxxxx xxxxxxxx xxxxxx xxxxxx PSČ:
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|
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E-mail:
|
Telefon:
|
Fax:
|
|
|
|
|
|
|
Razítko: Datum:
Úřední xxxxxxx:
(xxxxxxxxxx žadatel)
Žádost o xxxxxxxxxx xx xxxxxx xx dvou vyhotoveních!
Nevyplněné xxxxxxx xxxxxxxxxxx xxxxxxxxx xxxxx.
Xxxxxx x.........xxxxxxx
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Xxxxxxx xxxxx:
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|
Název xxxxxxx látky podle xxxxxxx nařízení Xxxx (XX) č. 111/2005
|
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|
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|
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Xxxxxxxxxxxxx xxxx xxxxxx:
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Xxxxxx x. ..........xxxxxxx
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Žadatel xxxxxxxx xxxxxxxxx xxxxxxx (originál, xxxxxxxxx xxxx xxxxxx xxxxxxx xxxxx).
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Xxxxx x xxxxxxxxxx xxxxxxxxx
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Xxxxxx/Xxxxxxxxxx x xxxxxxxx x podnikání
(např. xxxxxxxxxxxx xxxx, xxxxxxxx listina)
|
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Doklad/Rozhodnutí x xxxxxxxxxx xxxxxxxx, xxxxx xxxx xxxxxx x xxxxxxxxx xxxxxxxxx (xxxx. zřizovací xxxxxxx xxxxxx xxxxxxxxxxx xxxxxxx xxxxxxxxxx osoby, xxxxxx x přidělení XX)
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Xxxxxxx(x) x xxxxxxxxxxxxxx účelu xxxxxx xxxxxxx(x) x xxxxxxx
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Xxxxxxxxxx xxxxx xxxxxxxx xxxxxxx xxxx xxxxxxxxx
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Xxxxxxx č. 9 x vyhlášce x. 125/2006 Sb.
ŽÁDOST X XXXXXXXXXX
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Počet xxxxxx x žádosti:
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Počet listů xxxxxx příloh xxxxxx:
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Xxxxx (xxxxx a xxxx):*)
|
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Xxxxxxx xxxx o xxxxxxxxxx xxxxx xxxxxxxxx xxxxxx xx trh xxxxxxx xxxxx uvedené x xxxxxxxxx 2 přílohy xxxxxxxx Xxxxxxxxxx xxxxxxxxxx x Xxxx (XX) č. 273/2004
X. Xxxxxxx:
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Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / xxxxxxxx xxxxx / xxxxx x xxxxxxxx fyzické xxxxx) xxxxxx
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|
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Xxxxxx xxxxx:
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Xxxxxx xxxxxx PSČ:
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|
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Xxxxxx pro xxxxxxxxxx xxxxxx XXX:
xxxxx xx xxxxxxx xx xxxx xxxxxxx adresy
|
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Identifikační xxxxx (IČ):
|
|||||||||
Telefon:
|
Fax:
|
E-mail:
|
|||||||
II. Pomocná xxxxx:
&xxxx;
Xxx KN
|
Název xxxxxxx xxxxx xxxxx xxxxxxx X xxxxxxxx XXX (XX) č. 273/2004
|
&xxxx;
Xxxxxxxxxx, xxx xxxx xxxxxxxxxxxx xxxxxxx xxxxxxxxxx (uveďte xxxxxx xxxxxx XXX)
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&xxxx;
|
*) X xxxxxxx úhrady správního xxxxxxxx xxxxxxxxx známkami xxxxxx xxxxxx xxxxx x cenu.
Strana x. 1 xxxxxxx
XXXXXX O XXXXXXXXXX
xxxxx xxxxxxxxx xxxxxx xx xxx xxxxxxx xxxxx uvedené x xxxxxxxxx 2
&xxxx;
XX:
|
&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; |
&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; |
XX. Pomocná xxxxx (xxxxxxxxxxx):
&xxxx;
Xxx XX
|
&xxxx;
Xxxxx xxxxxxx xxxxx xxxxx xxxxxxx I xxxxxxxx XXX (XX) č. 273/2004
|
&xxxx;
Xxxxxxxxxx, xxx xxxx xxxxxxxxxxxx xxxxxxx xxxxxxxxxx (uveďte xxxxxx xxxxxx XXX)
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
|
&xxxx;
|
&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
Xxxxxx x. .........xxxxxxx
XXXXXX X XXXXXXXXXX
xxxxx xxxxxxxxx uvádět xx xxx xxxxxxx xxxxx xxxxxxx v xxxxxxxxx 2
&xxxx;
XX:
|
&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; |
&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; |
XXX. Xxxxxxx xxxxx oprávněné xxxxxx xxxxxx xxxxxxxx:
(xxxx. xxx xxxxxxxxxx xxxxxxxxx)
&xxxx;
|
&xxxx;
Xxxxx, xxxxxxxx, xxxxx:
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
1.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
2
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
3.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
4.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
XX. Xxxxxxxxx xxxxx:
&xxxx;
Xxxxx, xxxxxxxx, xxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxxxx místa xxxxxxxx pobytu xxxxxx XXX:
|
||
&xxxx;
|
||
&xxxx;
X-xxxx:
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
Xxxxxxx: Xxxxx:
Xxxxxx záznamy:
(nevyplňuje xxxxxxx)
&xxxx; |
&xxxx; |
Xxxxxx o xxxxxxxxxx xx xxxxxx xx xxxx xxxxxxxxxxxx!
Xxxxxxxxxx kolonky xxxxxxxxxxx xxxxxxxxx xxxxx.
Xxxxxx x.........xxxxxxx
Xxxxxxx x xxxxxxx x vydání xxxxxxxxxx xxxxx xxxxxxxxxxx xxxxxx xx trh xxxxxxx xxxxx xxxxxxxxx 2
Žadatel xxxxxxxx příslušné xxxxxxx (xxxxxxxx, stejnopis xxxx xxxxxx xxxxxxx xxxxx).
&xxxx;
Xxxxx xxxxxxx
|
&xxxx;
Xxxxx
xxxxx
|
&xxxx;
Xxxxx x Rejstříku xxxxxx (xx starší 3 měsíců) xxxxx xxxx xxxxxxxxxxx jednat xx žadatele
|
|
Výpis x xxxxxxxxxx xxxxxxxxx
|
&xxxx; |
&xxxx;
Xxxxxx/Xxxxxxxxxx o xxxxxxxx k xxxxxxxxx
(xxxx. xxxxxxxxxxxx list, xxxxxxxx xxxxxxx)
|
&xxxx; |
&xxxx;
Xxxxxx/Xxxxxxxxxx x totožnosti xxxxxxxx, xxxxx xxxx xxxxxx x xxxxxxxxx xxxxxxxxx (xxxx. zřizovací xxxxxxx xxxxxx xxxxxxxxxxx xxxxxxx statutární osoby, xxxxxx x přidělení XX)
|
&xxxx; |
&xxxx;
Xxxxxxxxxx další potřebné xxxxxxx xxxx neuvedené
|
|
Příloha č. 10 x vyhlášce x. 125/2006 Sb.
ŽÁDOST X XXXXXX XXXXXXXX K XXXXXX
xxxxxxxxxx xxxxx a xxxxxxxxx
&xxxx;
Xxxxx xxxxxx x xxxxxxx:
|
&xxxx; |
&xxxx;
Xxxxx listů xxxxxx xxxxxx xxxxxx:
|
&xxxx; |
&xxxx;
Xxxxx (xxxxx x cena):*)
|
|
Žadatel xxxx x xxxxxx xxxxxxxx x xxxxxx xxxxxxxxxx xxxxx a přípravků xxxxx §22 odst. 2 xxxxxx č. 167/1998 Xx.
X. Xxxxxxx (xxxxxxx):
&xxxx;
Xxxxx/xxxxx:
(xxxxx xxxxxxxxx osoby / obchodní firma / jméno x xxxxxxxx xxxxxxx xxxxx) xxxxxx
xxxxxxxxxxxx dodatku
|
|||||||||
Právní xxxxx:
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx xxxxxx XXX:
(xxxxx xxxxxxxxx xxxxx / xxxxx xxxxxxxx xxxxxx xxxxxxx xxxxx)
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx xxx xxxxxxxxxx xxxxxx XXX:
xxxxx je xxxxxxx od výše xxxxxxx xxxxxx
|
&xxxx; | ||||||||
&xxxx;
Xxxxxxxxxxxxx číslo (XX):
|
&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | |
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxx:
|
&xxxx;
X-xxxx:
|
|||||||
&xxxx; | &xxxx; | &xxxx; | |||||||
&xxxx; | &xxxx; | &xxxx; |
XX. Xxxxxxx x xxxxxxxx xxxxxxxxxxxxxxxx:
&xxxx;
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxxxxxxxxxxxxxxx:
(xxxxx, přes xxxxxx xx vývoz xxxxxxxx xxxxxxxxx)
|
&xxxx;
Xxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
XXX. Xxxxxxx xxxxxxxx:
&xxxx;
Xxxxx:
|
&xxxx; |
&xxxx;
Xxxxxx:
|
&xxxx; |
&xxxx;
Xxxx:
|
&xxxx; |
&xxxx; | &xxxx; |
*) X xxxxxxx xxxxxx xxxxxxxxx poplatku xxxxxxxxx známkami uveďte xxxxxx počet x xxxx.
Xxxxxx x. 1 xxxxxxx
XXXXXX O VYDÁNÍ XXXXXXXX X XXXXXX
xxxxxxxxxx xxxxx x xxxxxxxxx
XX. Xxxxxxxx látka nebo xxxxxxxxx:
&xxxx;
Xxxxx xxxxxxxx xxxxx xxxx přípravku
|
Množství
- xxxxx xxxxxx v gramech
- xxxxxxxxx x počtu xxxxxx
|
&xxxx;
Xxxxx xxxxxxxx látky xxxxxxxx v xxxxxxxxx
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
X. Xxxxxxx xxxxxxxx:
&xxxx;
Xxxxx:
|
&xxxx;
Xxxxx xxxxxxxxx:
|
&xxxx;
Xxxxxxxxx xxx:
|
&xxxx; | &xxxx; | &xxxx; |
&xxxx;
xxxx souhlas x xxxxxx (xxx §20 xxxx. 3 xxxxxx x. 167/1998 Xx.):
|
||
&xxxx; |
XX. Xxxx xxxxxx (Xxxxxx xx xxxxx xxxxxx xx má xxxxx xxxxxxxxxx):
&xxxx; |
&xxxx; |
&xxxx;
XXX. Xxxx xxxxxxxxx xxxxxxxxx xxxxxxxx xx:
|
&xxxx; |
&xxxx; | &xxxx; |
XXXX. Xxxxxxx osoby xxxxxxxxx xxxxxx xxxxxx xxxxxxxx:
(xxxx. xxx obchodního xxxxxxxxx)
&xxxx;
|
&xxxx;
Xxxxx, xxxxxxxx, xxxxx:
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
1.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
2
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
3.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
4.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
XX. Xxxxxxxxx xxxxx:
&xxxx;
Xxxxx, příjmení, titul:
|
Funkce:
|
Podpis:
|
|
|
|
Email:
|
Telefon:
|
Fax:
|
|
|
|
|
|
|
Razítko: Xxxxx:
Xxxxxxxxxx kolonky xxxxxxxxxxx xxxxxxxxx xxxxx.
Xxxxxx x. 2 xxxxxxx
Xxxxxxx č. 11 x xxxxxxxx č. 125/2006 Sb.
ŽÁDOST X XXXXXX XXXXXXXX X XXXXXX PREKURSORU
Počet xxxxxx x xxxxxxx:
|
&xxxx; |
&xxxx;
Xxxxx xxxxx xxxxxx příloh xxxxxx:
|
&xxxx; |
&xxxx;
Xxxxx (xxxxx x xxxx):*)
|
&xxxx; |
&xxxx; | &xxxx; |
Xxxxxxx xxxx o xxxxxx xxxxxxxx x vývozu xxxxxxxxxx čl. 13 xxxx. 1 xxxxxxxx Xxxx (ES) č. 111/2005
I. Xxxxxxx (xxxxxxx):
&xxxx;
Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / obchodní xxxxx / xxxxx x příjmení fyzické xxxxx) xxxxxx
xxxxxxxxxxxx xxxxxxx
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx xxxxx:
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx xxxxxx XXX:
(xxxxx xxxxxxxxx xxxxx / xxxxx xxxxxxxx xxxxxx xxxxxxx osoby)
|
|||||||||
Adresa pro xxxxxxxxxx xxxxxx PSČ:
pokud xx xxxxxxx od xxxx uvedené adresy
|
|||||||||
Identifikační xxxxx (XX):
|
&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | |
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxx:
|
&xxxx;
X-xxxx:
|
|||||||
&xxxx; | &xxxx; | &xxxx; | |||||||
&xxxx; | &xxxx; | &xxxx; |
XX. Xxxxxxx x xxxxxxxx zprostředkovatel:
|
Dovozce:
|
Zprostředkovatel:
(firma, xxxx kterou se xxxxx xxxxxxxx xxxxxxxxx)
|
&xxxx;
Xxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
XXX. Xxxxxxx příjemce:
Název:
|
|
Adresa:
|
|
Stát:
|
|
*) V xxxxxxx xxxxxx správního xxxxxxxx xxxxxxxxx známkami xxxxxx jejich xxxxx x xxxx.
Xxxxxx č. 1 xxxxxxx
XXXXXX X XXXXXX XXXXXXXX X XXXXXX XXXXXXXXXX
XX. Xxxxxxxxx:
&xxxx;
Xxxxx xxxxxxxxxx:
|
&xxxx;
Xxx XX
|
&xxxx;
Xxxxxxxx xxxxxx (xxxxx x g xxxx xx):
|
&xxxx;
% xx xxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxx xxxxxx:
|
&xxxx;
Xxxxx xxxxxx:
|
&xxxx;
Xxxxxxxx/xxxxx xxxxxxx balení (xxxxx x nebo xx):
|
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
X. Xxxxxxx povolení xxxx xxxxxxx x xxxxxx:
&xxxx;
Xxxxx:
|
&xxxx;
Xxxxx xxxxxxxxx:
|
&xxxx;
Xxxxxxxxx kým:
|
VI. Xxxx xxxxxx (Xxxxxx, xx xxxxx účelem se xx xxxxx xxxxxxxxxx):
&xxxx; |
&xxxx; |
XXX. Xxxxx:
&xxxx;
Xxxxx předpokládaného xxxxxx:
|
&xxxx; |
&xxxx;
Xxxxxxxxxxxxx xxxxx xxxxxx:
|
&xxxx; |
&xxxx; | &xxxx; |
XXXX. Xxxxxxxx:
&xxxx;
Xxxxx xxxxxxxxx xxxxx:
|
&xxxx; |
&xxxx;
Xxxxxx:
|
&xxxx; |
&xxxx;
Xxxx:
|
&xxxx; |
&xxxx;
Xxxx dopravního xxxxxxxxxx:
|
&xxxx; |
&xxxx;
Xxxxx xxxxxxxx:
|
&xxxx; |
&xxxx; | &xxxx; |
XX. Celnice:
Celní xxxx. kde xxxx xxxxxxx vývozní xxxxx xxxxxxxxxx: (xxxxxx)
|
&xxxx; |
&xxxx;
Xxxx x xxxxx xxxxxxx z XX:
|
&xxxx; |
&xxxx;
Xxxx x místo xxxxxx do xxxx xxxxxx:
|
&xxxx; |
&xxxx; | &xxxx; |
X. Fyzické osoby xxxxxxxxx jednat xxxxxx xxxxxxxx:
(xxxx. xxx xxxxxxxxxx xxxxxxxxx)
&xxxx;
|
&xxxx;
Xxxxx, příjmení, titul:
|
Telefon:
|
Funkce:
|
Podpis:
|
1.
|
|
|
|
|
2
|
|
|
|
|
3.
|
|
|
|
|
|
|
|
|
|
XI. Xxxxxxxxx osoba:
Jméno, xxxxxxxx, xxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxxx:
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
Xxxxxxx: Xxxxx:
Xxxxxxxxxx xxxxxxx xxxxxxxxxxx xxxxxxxxx čarou.
Strana x. 2 žádosti
Příloha č. 12 x xxxxxxxx č. 125/2006 Sb.
ŽÁDOST O XXXXXX XXXXXXXX X XXXXXX POMOCNÉ XXXXX
&xxxx;
Xxxxx xxxxxx x žádosti:
|
|
Počet xxxxx xxxxxx xxxxxx xxxxxx:
|
&xxxx; |
&xxxx;
Xxxxx (xxxxx x xxxx):*)
|
&xxxx; |
&xxxx; | &xxxx; |
Xxxxxxx žádá x xxxxxx povolení k xxxxxx pomocných xxxxx xxxxx xx. 13 xxxx. 1 xxxxxxxx Xxxx (XX) č. 111/2005
I. Xxxxxxx (vývozce):
Název/jméno:
(název xxxxxxxxx xxxxx / obchodní xxxxx / xxxxx x xxxxxxxx fyzické xxxxx) včetně
odlišujícího xxxxxxx
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx xxxxx:
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx xxxxxx XXX:
(xxxxx xxxxxxxxx xxxxx / xxxxx xxxxxxxx xxxxxx xxxxxxx xxxxx)
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx xxx xxxxxxxxxx včetně PSČ:
pokud xx xxxxxxx od xxxx xxxxxxx adresy
|
|||||||||
Identifikační xxxxx (XX):
|
&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | |
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxx:
|
&xxxx;
X-xxxx:
|
|||||||
&xxxx; | &xxxx; | &xxxx; | |||||||
&xxxx; | &xxxx; | &xxxx; |
XX. Dovozce x případně zprostředkovatel:
|
Dovozce:
|
Zprostředkovatel:
(firma, xxxx xxxxxx se xxxxx případně uskuteční)
|
Název:
|
|
|
Adresa:
|
|
|
Stát:
|
|
|
|
|
|
III. Xxxxxxx xxxxxxxx:
&xxxx;
Xxxxx:
|
&xxxx; |
&xxxx;
Xxxxxx:
|
&xxxx; |
&xxxx;
Xxxx:
|
&xxxx; |
&xxxx; | &xxxx; |
*) X xxxxxxx xxxxxx xxxxxxxxx xxxxxxxx xxxxxxxxx známkami xxxxxx xxxxxx xxxxx x cenu.
Strana č. 1 xxxxxxx
XXXXXX X XXXXXX XXXXXXXX K XXXXXX XXXXXXX LÁTKY
IV. Xxxxxxx xxxxx:
&xxxx;
Xxxxx xxxxxxx xxxxx:
|
&xxxx;
Xxx XX
|
&xxxx;
Xxxxxxxx xxxxxx (xxxxx v kg xxxx x):
|
&xxxx;
% ve xxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxx xxxxxx:
|
&xxxx;
Xxxxx xxxxxx:
|
&xxxx;
Xxxxxxxx/xxxxx xxxxxxx xxxxxx (xxxxx x kg xxxx x):
|
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
X. Xxxxxxx xxxxxxxx xxxx xxxxxxx x xxxxxx:
&xxxx;
Xxxxx:
|
&xxxx;
Xxxxx xxxxxxxxx:
|
&xxxx;
Xxxxxxxxx kým:
|
VI. Xxxx xxxxxx (Xxxxxx, xx xxxxx účelem xx xx xxxxx xxxxxxxxxx):
&xxxx; |
&xxxx; |
XXX. Xxxxx:
&xxxx;
Xxxxx předpokládaného xxxxxx:
|
&xxxx; |
&xxxx;
Xxxxxxxxxxxxx xxxxx xxxxxx:
|
&xxxx; |
&xxxx; | &xxxx; |
XXXX. Xxxxxxxx:
&xxxx;
Xxxxx xxxxxxxxx firmy:
|
|
Adresa:
|
|
Stát:
|
|
Druh xxxxxxxxxx xxxxxxxxxx:
|
&xxxx; |
&xxxx;
Xxxxx xxxxxxxx:
|
&xxxx; |
&xxxx; | &xxxx; |
XX. Xxxxxxx:
&xxxx;
Xxxxx úřad. kde xxxx uloženo xxxxxxx xxxxx xxxxxxxxxx: (adresa)
|
|
Stát x xxxxx xxxxxxx x XX:
|
&xxxx; |
&xxxx;
Xxxx x xxxxx xxxxxx xx xxxx xxxxxx:
|
&xxxx; |
&xxxx; | &xxxx; |
X. Fyzické xxxxx xxxxxxxxx xxxxxx xxxxxx xxxxxxxx:
(xxxx. xxx xxxxxxxxxx xxxxxxxxx)
&xxxx;
|
&xxxx;
Xxxxx, příjmení, xxxxx:
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
1.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
2
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
3.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
XX. Odpovědná osoba:
Jméno, xxxxxxxx, titul:
|
Funkce:
|
Podpis:
|
|
|
|
Email:
|
Telefon:
|
Fax:
|
|
|
|
|
|
|
Razítko: Xxxxx:
Xxxxxxxxxx xxxxxxx xxxxxxxxxxx xxxxxxxxx xxxxx.
Xxxxxx x. 2 xxxxxxx
Xxxxxxx x. 13 x xxxxxxxx č. 125/2006 Sb.
ŽÁDOST O XXXXXX POVOLENÍ X XXXXXX XXXXXXX XXXXX
xxxxxxxxxxxxx xxxxxxxx
&xxxx;
Xxxxx xxxxxx x xxxxxxx:
|
&xxxx; |
&xxxx;
Xxxxx xxxxx xxxxxx xxxxxx xxxxxx:
|
&xxxx; |
&xxxx;
Xxxxx (počet x xxxx):*)
|
&xxxx; |
&xxxx; | &xxxx; |
Xxxxxxx žádá x xxxxxx povolení x xxxxxx xxxxxxxxx xxxxx zjednodušeným xxxxxxxx xxxxx xx. 13 xxxx. 1 xxxxxxxx Xxxx (XX) č. 111/2005
X. Xxxxxxx (xxxxxxx):
&xxxx;
Xxxxx/xxxxx:
(xxxxx právnické xxxxx / obchodní xxxxx / jméno x xxxxxxxx xxxxxxx xxxxx) včetně
odlišujícího dodatku
|
|||||||||
Právní xxxxx:
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx xxxxxx PSČ:
(sídla xxxxxxxxx xxxxx / xxxxx xxxxxxxx xxxxxx xxxxxxx osoby)
|
|||||||||
Adresa pro xxxxxxxxxx včetně XXX:
xxxxx xx xxxxxxx od xxxx uvedené xxxxxx
|
&xxxx; | ||||||||
&xxxx;
Xxxxxxxxxxxxx xxxxx (IČ):
|
|||||||||
Telefon:
|
Fax:
|
E-mail:
|
|||||||
II. Xxxxxxx x případně xxxxxxxxxxxxxxxx:
&xxxx;
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxxxxxxxxxxxxxxx:
(xxxxx, xxxx xxxxxx xx xxxxx xxxxxxxx xxxxxxxxx)
|
&xxxx;
Xxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
XXX. Xxxxxxx xxxxxxxx:
&xxxx;
Xxxxx:
|
&xxxx; |
&xxxx;
Xxxxxx:
|
&xxxx; |
&xxxx;
Xxxx:
|
&xxxx; |
&xxxx; | &xxxx; |
*) X xxxxxxx xxxxxx xxxxxxxxx xxxxxxxx xxxxxxxxx xxxxxxxx xxxxxx jejich xxxxx x xxxx.
Xxxxxx x. 1 xxxxxxx
XXXXXX X XXXXXX POVOLENÍ K XXXXXX XXXXXXX LÁTKY
zjednodušeným xxxxxxxx
XX. Pomocná látka:
Název xxxxxxx xxxxx:
|
&xxxx;
Xxx XX
|
&xxxx;
Xxxxxxx xxxxxxxx xxxxxxxx pomocné xxxxx (xxxxx v xx nebo x):
|
&xxxx;
% xx xxxxx:
|
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
|
&xxxx;
Xxxxxxxxxxxxx termín xxxxxxxxxxx xxxxxxx:
|
&xxxx;
Xxxxx xxxxxxx:
|
&xxxx;
Xxxxxxxx xxxxxxxx/xxxxx jedné dodávky (xxxxx x kg xxxx l):
|
||
od:
|
do:
|
|
|
|
|
|
|
|
V. Dovozní xxxxxxxx:
&xxxx;
Xxxxx:
|
&xxxx;
Xxxxx xxxxxxxxx:
|
&xxxx;
Xxxxxxxxx xxx:
|
&xxxx; | &xxxx; | &xxxx; |
&xxxx;
xxxx xxxxxxx x xxxxxx (xxx §20 odst. 3 zákona x. 167/1998 Xx.):
|
||
&xxxx; |
XX. Xxxx xxxxxx (Uveďte, xx xxxxx xxxxxx xx xx xxxxx uskutečnit):
VII. Xxxxxxxx:
&xxxx;
Xxxxx xxxxxxxxx xxxxx:
|
&xxxx; |
&xxxx;
Xxxxxx:
|
&xxxx; |
&xxxx;
Xxxx:
|
&xxxx; |
&xxxx;
Xxxx xxxxxxxxxx xxxxxxxxxx:
|
&xxxx; |
&xxxx;
Xxxxx xxxxxxxx:
|
&xxxx; |
&xxxx; | &xxxx; |
XXXX. Xxxxxxx:
&xxxx;
Xxxxx xxxx. xxx xxxx uloženo vývozní xxxxx prohlášení: (xxxxxx)
|
&xxxx; |
&xxxx;
Xxxx x místo xxxxxxx x XX:
|
&xxxx; |
&xxxx;
Xxxx x xxxxx xxxxxx do xxxx xxxxxx:
|
&xxxx; |
&xxxx; | &xxxx; |
XX. Xxxxxxx xxxxx oprávněné jednat xxxxxx xxxxxxxx:
(xxxx. xxx xxxxxxxxxx xxxxxxxxx)
&xxxx;
|
&xxxx;
Xxxxx, xxxxxxxx, xxxxx:
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
1.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
2
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
3.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
X. Xxxxxxxxx osoba:
Jméno, xxxxxxxx, titul:
|
Funkce:
|
Podpis:
|
|
|
|
Email:
|
Telefon:
|
Fax:
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Razítko: Xxxxx:
Xxxxxxxxxx xxxxxxx proškrtněte xxxxxxxxx xxxxx.
Xxxxxx č. 2 xxxxxxx
Xxxxxxx č. 14 x xxxxxxxx x. 125/2006 Sb.
ŽÁDOST O XXXXXX POVOLENÍ X XXXXXX
xxxxxxxxxx xxxxx x xxxxxxxxx
&xxxx;
Xxxxx xxxxxx x xxxxxxx:
|
&xxxx; |
&xxxx;
Xxxxx xxxxx těchto xxxxxx celkem:
|
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Kolky (xxxxx x cena):*)
|
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Žadatel žádá x vydání povolení x dovozu návykových xxxxx x xxxxxxxxx xxxxx §22 odst. 2 xxxxxx x. 167/1998 Xx.
X. Xxxxxxx (xxxxxxx):
&xxxx;
Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / xxxxxxxx xxxxx / xxxxx x xxxxxxxx xxxxxxx xxxxx) xxxxxx
xxxxxxxxxxxx xxxxxxx
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx forma:
|
|||||||||
Adresa xxxxxx PSČ:
(sídla xxxxxxxxx xxxxx / místa xxxxxxxx pobytu xxxxxxx xxxxx)
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx pro xxxxxxxxxx xxxxxx XXX:
xxxxx je xxxxxxx xx xxxx xxxxxxx xxxxxx
|
&xxxx; | ||||||||
&xxxx;
Xxxxxxxxxxxxx číslo (XX):
|
&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | |
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxx:
|
&xxxx;
X-xxxx:
|
|||||||
&xxxx; | &xxxx; | &xxxx; | |||||||
&xxxx; | &xxxx; | &xxxx; |
XX. Xxxxxxx x xxxxxxxx xxxxxxxxxxxxxxxx:
&xxxx;
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxxxxxxxxxxxxxxx:
(xxxxx, xxxx xxxxxx se dovoz xxxxxxxx xxxxxxxxx)
|
&xxxx;
Xxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
XXX. Xxxxxxxx xxxxx xxxx xxxxxxxxx:
&xxxx;
Xxxxx xxxxxxxx xxxxx nebo xxxxxxxxx
|
&xxxx;
Xxxxxxxx
- xxxxx uveďte x xxxxxxx
- xxxxxxxxx x počtu balení
|
Název xxxxxxxx látky obsažené x přípravku
|
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V xxxxxxx xxxxxxxxxx xxxxx xxxxxxxxxx xx straně x. 3 xxxxxxx
|
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&xxxx;
|
*) X xxxxxxx xxxxxx xxxxxxxxx xxxxxxxx xxxxxxxxx xxxxxxxx xxxxxx xxxxxx počet x xxxx.
Xxxxxx x. 1 xxxxxxx
XXXXXX O XXXXXX POVOLENÍ K XXXXXX
xxxxxxxxxx látek x xxxxxxxxx
XX. Xxxx dovozu:
Uveďte:
ano / xx
|
&xxxx;
X xxxxxx xxx výrobce nebo xxxxx. xxxxxxxx xxxx xxx xxxxx xxxxx xxxxxx uveďte xxxxx/xxxxx x xxxxxx xxxxx, xxx kterou xx xxxxx realizuje, xxxxxx xxxxxx xxxxxxxxxxx, pokud xx liší od xxxxxx xxxxx/xxxxx xxxxxxxx xxxxxx xxxx xxxxx.
|
|
&xxxx;
Xxxxxxx:
|
&xxxx; | &xxxx; |
&xxxx;
Xxxxxxxxxxx:
|
&xxxx; | &xxxx; |
&xxxx;
Xxxxxxx:
|
&xxxx; | &xxxx; |
&xxxx;
Xxxxx. xxxxxxxx:
|
&xxxx; | &xxxx; |
&xxxx;
Xxxx:
|
&xxxx; | &xxxx; |
&xxxx;
Xxxxxx:
|
&xxxx; | &xxxx;
X xxxxxxx, že xxxxxxxxx (xxxxxxxx) xx xxxxxxx uvedený v xxxxxxx xx vyhlášce x. 83/2002 Sb., xxxxxx konkrétní xxxx xxxxxx
|
&xxxx; | &xxxx; | &xxxx; |
&xxxx; | &xxxx; | &xxxx; |
X. Místo xxxxxxxxxxx x xxxxxxxx (dovozce):
[vyplňte xxxxx xxxxx xx xxxx xx adresy xxxxxxxx (dovozce) x xxxxx X]
&xxxx;
Xxxxxx skladu xxxxxx XXX
|
&xxxx; |
&xxxx; | &xxxx; |
XX. Xxxxxxx xxxxx xxxxxxxxx jednat xxxxxx xxxxxxx:
(xxxx. xxx xxxxxxxxxx rejstříku)
|
Jméno, příjmení, xxxxx:
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
1.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
2
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
3.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
XXX. Xxxxxxxxx xxxxx:
&xxxx;
Xxxxx, xxxxxxxx, xxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxxx:
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
Xxxxxxx: Datum:
Nevyplněné xxxxxxx xxxxxxxxxxx xxxxxxxxx xxxxx.
Xxxxxx x. 2 xxxxxxx
XXXXXX X VYDÁNÍ XXXXXXXX X XXXXXX
xxxxxxxxxx xxxxx a xxxxxxxxx
Xxxxxxxxxxx xxxx XXX žádosti
Název xxxxxxxx xxxxx xxxx xxxxxxxxx
|
&xxxx;
Xxxxxxxx
- látky xxxxxx x xxxxxxx
- xxxxxxxxx x počtu xxxxxx
|
&xxxx;
Xxxxx xxxxxxxx xxxxx xxxxxxxx x přípravku
|
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Strana x. 3 xxxxxxx
Xxxxxxx č. 15 x xxxxxxxx x. 125/2006 Xx.
XXXXXX O XXXXXX XXXXXXXX K XXXXXX XXXXXXXXXX
&xxxx;
Xxxxx xxxxxx x xxxxxxx:
|
&xxxx; |
&xxxx;
Xxxxx xxxxx xxxxxx xxxxxx celkem:
|
|
Kolky (xxxxx x xxxx):*)
|
&xxxx; |
&xxxx; | &xxxx; |
Xxxxxxx xxxx x xxxxxx xxxxxxxx x xxxxxx xxxxxxxxxx xxxxx xx. 21 xxxx. 1 xxxxxxxx Rady (ES) č. 111/2005
X. Žadatel (xxxxxxx):
&xxxx;
Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / xxxxxxxx firma / xxxxx a xxxxxxxx xxxxxxx xxxxx) xxxxxx
xxxxxxxxxxxx xxxxxxx
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx xxxxx:
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx xxxxxx XXX:
(xxxxx xxxxxxxxx xxxxx / xxxxx xxxxxxxx xxxxxx xxxxxxx osoby)
|
|||||||||
Adresa xxx xxxxxxxxxx xxxxxx XXX:
xxxxx xx xxxxxxx xx xxxx uvedené xxxxxx
|
&xxxx; | ||||||||
&xxxx;
Xxxxxxxxxxxxx xxxxx (IČ):
|
|||||||||
Telefon:
|
Fax:
|
E-mail:
|
|||||||
II. Xxxxxxx x případně xxxxxxxxxxxxxxxx:
&xxxx;
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxxxxxxxxxxxxxxx:
(xxxxx, přes xxxxxx xx xxxxx xxxxxxxx xxxxxxxxx)
|
&xxxx;
Xxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
XXX. Xxxxxxx xxxxxxxx:
&xxxx;
Xxxxx:
|
&xxxx; |
&xxxx;
Xxxxxx:
|
&xxxx; |
&xxxx;
Xxxx:
|
&xxxx; |
&xxxx; | &xxxx; |
*) X xxxxxxx úhrady xxxxxxxxx xxxxxxxx kolkovými xxxxxxxx xxxxxx xxxxxx xxxxx a xxxx.
Xxxxxx x. 1 xxxxxxx
XXXXXX X XXXXXX XXXXXXXX X XXXXXX XXXXXXXXXX
XX. Xxxxxxxxx:
&xxxx;
Xxxxx prekursoru:
|
Kód XX
|
&xxxx;
Xxxxxxxx xxxxxx (xxxxx v x xxxx ml):
|
% xx xxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxx xxxxxx:
|
&xxxx;
Xxxxx xxxxxx:
|
&xxxx;
Xxxxxxxx/xxxxx xxxxxxx xxxxxx (xxxxx x g xxxx xx):
|
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
X. Xxxx xxxxxx (Xxxxxx, xx xxxxx účelem xx xx xxxxx xxxxxxxxxx):
&xxxx; |
&xxxx; |
XX. Xxxxx:
&xxxx;
Xxxxx xxxxxxxxxxxxxxx dovozu:
|
|
VII. Xxxxxxxx:
&xxxx;
Xxxxx přepravní xxxxx:
|
&xxxx; |
&xxxx;
Xxxxxx:
|
&xxxx; |
&xxxx;
Xxxx:
|
&xxxx; |
&xxxx;
Xxxx xxxxxxxxxx prostředku:
|
|
Trasa xxxxxxxx:
|
&xxxx; |
&xxxx; | &xxxx; |
XXXX. Xxxxxxx:
&xxxx;
Xxxxx xxxx, xxx xxxx uloženo dovozní xxxxx prohlášení: (adresa)
|
|
Stát x xxxxx xxxxxx xx ES:
|
|
IX. Xxxxxxx xxxxx oprávněné xxxxxx xxxxxx xxxxxxxx:
(xxxx. xxx xxxxxxxxxx rejstříku)
|
Jméno, příjmení, xxxxx:
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
1.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
2
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
3.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
X. Xxxxxxxxx xxxxx:
&xxxx;
Xxxxx, xxxxxxxx, xxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxxx:
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
Xxxxxxx: Xxxxx:
Xxxxxxxxxx xxxxxxx xxxxxxxxxxx xxxxxxxxx xxxxx.
Xxxxxx č. 2 xxxxxxx
Příloha č. 16 x xxxxxxxx č. 125/2006 Sb.
ŽÁDOST X XXXXXX XXXXXXXX X XXXXXX XXXXXXXX
&xxxx;
Xxxxx xxxxxx x xxxxxxx:
|
&xxxx; |
&xxxx;
Xxxxx xxxxx xxxxxx xxxxxx celkem:
|
|
Kolky (xxxxx a xxxx):*)
|
&xxxx; |
&xxxx; | &xxxx; |
Xxxxxxx xxxx x xxxxxx xxxxxxxx k xxxxxx xxxxxxxx xxxxx §25 xxxx. 1 xxxxxx x. 167/1998 Xx.
X. Xxxxxxx (vývozce):
Název/jméno:
(název xxxxxxxxx xxxxx / xxxxxxxx xxxxx / jméno x xxxxxxxx xxxxxxx xxxxx) xxxxxx
xxxxxxxxxxxx xxxxxxx
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx xxxxx:
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx xxxxxx XXX:
(xxxxx xxxxxxxxx xxxxx / xxxxx xxxxxxxx xxxxxx xxxxxxx xxxxx)
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx pro xxxxxxxxxx xxxxxx XXX:
xxxxx xx xxxxxxx xx xxxx xxxxxxx xxxxxx
|
&xxxx; | ||||||||
&xxxx;
Xxxxxxxxxxxxx xxxxx (XX):
|
&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | |
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxx:
|
&xxxx;
X-xxxx:
|
|||||||
&xxxx; | &xxxx; | &xxxx; | |||||||
&xxxx; | &xxxx; | &xxxx; |
XX. Xxxxxxx:
&xxxx;
Xxxxx:
|
&xxxx; |
&xxxx;
Xxxxxx:
|
&xxxx; |
&xxxx;
Xxxx:
|
&xxxx; |
&xxxx; | &xxxx; |
XXX. Xxxxxxx xxxxxxxx (pokud xx xxxxxxx xx xxxxxxx):
&xxxx;
Xxxxx:
|
&xxxx; |
&xxxx;
Xxxxxx:
|
&xxxx; |
&xxxx;
Xxxx:
|
&xxxx; |
&xxxx; | &xxxx; |
*) V xxxxxxx xxxxxx xxxxxxxxx xxxxxxxx xxxxxxxxx xxxxxxxx uveďte xxxxxx xxxxx x xxxx.
Xxxxxx x. 1 xxxxxxx
XXXXXX X VYDÁNÍ XXXXXXXX X VÝVOZU XXXXXXXX
XX. Xxxxxxxx:
&xxxx;
Xxxxxxx xxxxxxxx xxxxxxxx xxxxxxxx x xx:
|
||||||
&xxxx;
Xxxxxxxx bude xxxxxxxx:
(xxxxxxxxxxx x vyplněním xxxxxxx xxxxx z níže xxxxxxxxx možností)
|
||||||
najednou
|
v dílčích xxxxxxxxx
|
|||||
&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | |
&xxxx;
Xxxxxxxxxxxxx xxxxx xxxxxx:
|
&xxxx;
Xxxxxxxxxxxxx xxxxxx xxxxxxxxxxx xxxxxxx
|
|||||
&xxxx; | &xxxx;
xx:
|
&xxxx;
xx:
|
||||
&xxxx; | &xxxx; | &xxxx; |
X. Xxxxxxx povolení:
Číslo:
|
Datum vystavení:
|
Vystaveno xxx:
|
&xxxx; | &xxxx; | &xxxx; |
&xxxx;
xxxx souhlas x xxxxxx (xxx §20 xxxx. 3 xxxxxx x. 167/1998 Xx.):
|
||
&xxxx; |
XX. Xxxx xxxxxx (Xxxxxx, xx jakým xxxxxx xx xx xxxxx xxxxxxxxxx):
&xxxx; |
&xxxx; |
XXX. Xxxxxxx xxxxx xxxxxxxxx jednat jménem xxxxxxxx:
(xxxx. xxx xxxxxxxxxx xxxxxxxxx)
&xxxx;
|
&xxxx;
Xxxxx, xxxxxxxx, xxxxx:
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
1.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
2
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
3.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
XXXX. Xx xxxxxxxxx odpovídá:
Jméno, xxxxxxxx, xxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxxx:
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
Xxxxxxx: Xxxxx:
Xxxxxxxxxx xxxxxxx xxxxxxxxxxx souvislou xxxxx.
Xxxxxx x. 2 xxxxxxx
Xxxxxxx k xxxxxxx x xxxxxx povolení x vývozu xxxxxxxx
Xxxxxxx xxxxxxxx příslušné xxxxxxx (xxxxxxxx, stejnopis xxxx xxxxxx ověřená xxxxx).
&xxxx;
Xxxxx xxxxxxx
|
&xxxx;
Xxxxx
xxxxx
|
&xxxx;
Xxxxxxxxx dovozního xxxxxxxx xxxxxxxx xxxxxx, xxx xx xxx vývoz xxxxxxxxxx
(§20 xxxx. 3 xxxxxx x. 167/1998 Xx.)
|
&xxxx; |
&xxxx;
Xxxxxxx příslušného státního xxxxxx xxxxx, xxx xx xxx xxxxx xxxxxxxxxx, pokud xxxxx xxxx xxxxxxxx xxxxxxx xxxxxxxx (§20 odst. 3 zákona x. 167/1998 Xx.)
|
&xxxx; |
&xxxx;
Xxxxx z xxxxxxxxxx rejstříku
|
|
Doklad/Rozhodnutí x xxxxxxxx x xxxxxxxxx
(xxxx. xxxxxxxxx x xxxxxx xx xxxxxxxx xxxxxxxx xxxxxxxxxxxxx xxxxxxx, xxxxxxxxxxxx xxxx)
|
&xxxx; |
&xxxx;
Xxxxxxxxxx další xxxxxxxx xxxxxxx xxxx xxxxxxxxx
|
&xxxx; |
&xxxx; | &xxxx; |
Příloha x. 17 x xxxxxxxx x. 125/2006 Xx.
XXXXXX X XXXXXX XXXXXXXX K XXXXXX MAKOVINY
Počet xxxxxx x žádosti:
|
|
Počet listů xxxxxx xxxxxx xxxxxx:
|
&xxxx; |
&xxxx;
Xxxxx (xxxxx x xxxx):*)
|
&xxxx; |
&xxxx; | &xxxx; |
Xxxxxxx xxxx x xxxxxx xxxxxxxx x xxxxxx xxxxxxxx xxxxx §25 xxxx. 1 xxxxxx x. 167/1998 Xx.
X. Xxxxxxx (xxxxxxx):
&xxxx;
Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / xxxxxxxx xxxxx / xxxxx x xxxxxxxx xxxxxxx xxxxx) xxxxxx
xxxxxxxxxxxx xxxxxxx
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx xxxxx:
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx včetně XXX:
(xxxxx xxxxxxxxx xxxxx / xxxxx xxxxxxxx xxxxxx xxxxxxx xxxxx)
|
&xxxx; | ||||||||
&xxxx;
Xxxxxx xxx xxxxxxxxxx xxxxxx PSČ:
pokud xx xxxxxxx xx xxxx xxxxxxx xxxxxx
|
&xxxx; | ||||||||
&xxxx;
Xxxxxxxxxxxxx xxxxx (IČ):
|
|||||||||
Telefon:
|
Fax:
|
E-mail:
|
|||||||
II. Xxxxxxx:
&xxxx;
Xxxxx:
|
&xxxx; |
&xxxx;
Xxxxxx:
|
&xxxx; |
&xxxx;
Xxxx:
|
&xxxx; |
&xxxx; | &xxxx; |
XXX. Xxxxxxx xxxxxxxx (xxxxx xx xxxxxxx xx xxxxxxx):
&xxxx;
Xxxxx:
|
&xxxx; |
&xxxx;
Xxxxxx:
|
&xxxx; |
&xxxx;
Xxxx:
|
&xxxx; |
&xxxx; | &xxxx; |
*) X případě xxxxxx správního poplatku xxxxxxxxx známkami xxxxxx xxxxxx počet x xxxx.
Xxxxxx č. 1 xxxxxxx
XXXXXX X XXXXXX XXXXXXXX K XXXXXX XXXXXXXX
XX. Xxxxxxxx:
&xxxx;
Xxxxxxx xxxxxxxx xxxxxxxx xxxxxxxx x xx:
|
||||||
&xxxx;
Xxxxxxxx xxxx dovezena:
(zaškrtnutím x vyplněním xxxxxxx xxxxx x xxxx xxxxxxxxx xxxxxxxx)
|
||||||
&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | |
&xxxx; | &xxxx; | &xxxx;
xxxxxxxx
|
&xxxx; | &xxxx; | &xxxx;
x xxxxxxx xxxxxxxxx
|
|
&xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | &xxxx; | |
&xxxx;
Xxxxxxxxxxxxx datum xxxxxx:
|
&xxxx;
Xxxxxxxxxxxxx xxxxxx xxxxxxxxxxx xxxxxxx
|
|||||
&xxxx; | &xxxx;
xx:
|
&xxxx;
xx:
|
||||
&xxxx; | &xxxx; | &xxxx; |
X. Xxxx dovozu (Xxxxxx, xx xxxxx xxxxxx xx xx xxxxx xxxxxxxxxx):
&xxxx; |
&xxxx; |
XX. Fyzické osoby xxxxxxxxx xxxxxx xxxxxx xxxxxxxx:
(xxxx. xxx obchodního xxxxxxxxx)
&xxxx;
|
&xxxx;
Xxxxx, příjmení, xxxxx:
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
1.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
2
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
3.
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
XXX. Xx xxxxxxxxx xxxxxxxx:
&xxxx;
Xxxxx, xxxxxxxx, xxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxxxx:
|
&xxxx;
Xxxxxxx:
|
&xxxx;
Xxx:
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
Xxxxxxx: Xxxxx:
Xxxxxxxxxx xxxxxxx proškrtněte xxxxxxxxx xxxxx.
Xxxxxx x. 2 xxxxxxx
Xxxxxxx x xxxxxxx x xxxxxx xxxxxxxx x xxxxxx xxxxxxxx
Xxxxxxx xxxxxxxx příslušné xxxxxxx (xxxxxxxx, stejnopis xxxx xxxxxx xxxxxxx xxxxx).
&xxxx;
Xxxxx xxxxxxx
|
&xxxx;
Xxxxx
xxxxx
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|
|
Eventuálně xxxxx xxxxxxxx xxxxxxx xxxx neuvedené
|
|
Xxxxxxx x. 18 x xxxxxxxx č. 125/2006 Xx.
XXXXXXX HLÁŠENÍ
o xxxxxxxxxxxx DOVOZU návykových xxxxx a xxxxxxxxx
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Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / xxxxxxxx xxxxx / xxxxx x příjmení xxxxxxx xxxxx) včetně xxxxxxxxxxxx xxxxxxx
|
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|
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Xxxxxx xxxxxx XXX:
(xxxxx právnické xxxxx / místa xxxxxxxx xxxxxx fyzické xxxxx)
|
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|
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&xxxx;
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x xxxxxxxxxxxx XXXXXX xxxxxxxxxx xxxxx a xxxxxxxxx
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|
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Xxxxxxxxxxxxx xxxxx (XX):
|
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|
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|
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Xxxxxxxx xxxxx xxxx xxxxxxxxx
|
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|
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|
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Xxxxx xxxxxxxxx xxxxxxxx
|
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Xxxxx xxxxxxxxxxxx xxxxxxxxx povolení
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|
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|
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|
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|
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|
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Xxxxxx x. ........ xxxxxxx
Xxxxxxx x. 19 x xxxxxxxx č. 125/2006 Xx.
XXXXXXX
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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Xxxxx xxxxxxxxx povolení
|
Číslo xxxxxxxxxxxx vývozního xxxxxxxx
|
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|
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|
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|
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|
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|
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|
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|
|||||||||||||||
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|
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|
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|
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|
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(xxxxx xxxxxxxxx osoby i xxxxxxxx xxxxx / xxxxx x xxxxxxxx xxxxxxx xxxxx) xxxxxx xxxxxxxxxxxx xxxxxxx
|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
Xxxxxx x. ........ xxxxxxx
Xxxxxxx x. 20 x xxxxxxxx č. 125/2006 Xx.
XXXXXXX XXXXXXX
x xxxxxxxxxxxx XXXXXX návykových xxxxx a přípravků
Název/jméno:
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|
|
Adresa xxxxxx XXX:
(xxxxx právnické xxxxx / místa trvalého xxxxxx xxxxxxx xxxxx)
|
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|
|||||||||||||||
&xxxx;
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x xxxxxxxxxxxx XXXXXX xxxxxxxxxx látek x xxxxxxxxx
xxxxx §26 xxxx. 1 písm. x) xxxxxx č. 167/1998 Xx.
|
||||||||||||||||||
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Xxxxxxxxxxxxx číslo (XX):
|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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Xxxxxxxx xxxxx nebo xxxxxxxxx
|
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- přípravky x xxxxx xxxxxx
|
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Xxxxx
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|
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Xxxxx xxxxxxxxx xxxxxxxx
|
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Xxxxx zahraničního xxxxxxxxx povolení
|
||||||||||||||
|
|
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|
||||||||||||||
|
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|
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|
||||||||||||||
|
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Jméno a xxxxxxxx xxxxxxxxx xxxx xxxxxxxxxxx xxxxxx xx xxxxxxxxxxxxx xxxxxxxxx hlášení (xxxx. xxx obchodního xxxxxxxxx):
|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
&xxxx;
|
&xxxx;
|
&xxxx;
|
Xxxxxxxxxx xxxxxxx proškrtněte xxxxxxxxx čarou.
Strana x. 1 xxxxxxx
&xxxx;
Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / xxxxxxxx xxxxx / xxxxx x příjmení fyzické xxxxx) xxxxxx xxxxxxxxxxxx xxxxxxx
|
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Xxxxxx xxxxxx PSČ:
(sídla xxxxxxxxx xxxxx / xxxxx trvalého xxxxxx xxxxxxx xxxxx)
|
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|
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|
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Xxxxxxxx xxxxx xxxx xxxxxxxxx
|
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Xxxxxxxx
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- xxxxxxxxx x xxxxx xxxxxx
|
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Xxxxx xxxxxx
|
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Xxxxx xxxxxxxxx povolení
|
Číslo xxxxxxxxxxxx dovozního povolení
|
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Strana x. ........ hlášení
Xxxxxxx x. 21 x vyhlášce x. 125/2006 Xx.
XXXXXXX
x xxxxxxxxxxxx XXXXXX xxxxxxxxxx
&xxxx;
Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / xxxxxxxx xxxxx / jméno x xxxxxxxx fyzické xxxxx) včetně xxxxxxxxxxxx xxxxxxx
|
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|
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|
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|
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x xxxxxxxxxxxx XXXXXX prekursorů
podle xxxxxxxx Xxxx (XX) č. 111/2005
|
||||||||||||||||||
Identifikační xxxxx (XX):
|
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|
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|
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|
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|
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|
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|
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|
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|
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Xxxxx a xxx, xx xxxxx xx hlášení xxxxxx:
|
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|
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|
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|
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|
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|
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|
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Xxxxx xxxxxxxxxxxx dovozního xxxxxxxx
|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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Xxxxx xxxxx xxxxxxx celkem:
|
|
|||||||||||||||
|
|
|
|
Nevyplněné xxxxxxx xxxxxxxxxxx souvislou xxxxx.
Xxxxxx x. 1 xxxxxxx
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Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / xxxxxxxx xxxxx / xxxxx x příjmení xxxxxxx xxxxx) xxxxxx xxxxxxxxxxxx xxxxxxx
|
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Xxxxxx včetně XXX:
(xxxxx xxxxxxxxx xxxxx / xxxxx trvalého xxxxxx xxxxxxx osoby)
|
|
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HLÁŠENÍ x xxxxxxxxxxxx XXXXXX xxxxxxxxxx
|
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|
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|
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Xxxxxx x. ........ xxxxxxx
Xxxxxxx x. 22 x xxxxxxxx x. 125/2006 Sb.
HLÁŠENÍ
o uskutečněném XXXXXX xxxxxxxxx látek
Název/jméno:
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|
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|
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Xxxxxx včetně XXX:
(xxxxx právnické osoby / místa xxxxxxxx xxxxxx xxxxxxx xxxxx)
|
&xxxx;
|
|||||||||||||||
&xxxx;
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x xxxxxxxxxxxx XXXXXX xxxxxxxxx xxxxx
xxxxx §28 odst. 1 xxxx. x) xxxxxx x. 167/1998 Xx.
|
||||||||||||||||||
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
||||||||
&xxxx;
|
||||||||||||||||||
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Xxxxxxx xxxxx
|
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Xxxxxxxx
x kg xxxx litrech
|
Datum
vývozu
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Xxxxxx č. ........ xxxxxxx
Příloha x. 23 x xxxxxxxx x. 125/2006 Xx.
XXXXXXXXXX XXXXXXX
x xxxxxxxxxxxx XXXXXX xxxxxxxx
&xxxx;
Xxxxx/xxxxx:
(xxxxx xxxxxxxxx osoby / xxxxxxxx xxxxx / xxxxx x příjmení xxxxxxx osoby) včetně xxxxxxxxxxxx dodatku
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Adresa xxxxxx XXX:
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Strana č. .... xxxxxxx
Xxxxxxx x. 24 x vyhlášce č. 125/2006 Xx.
XXXXXXXXXX XXXXXXX
x xxxxxxxxxxxx DOVOZU xxxxxxxx
&xxxx;
Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / xxxxxxxx firma / xxxxx x xxxxxxxx xxxxxxx xxxxx) xxxxxx xxxxxxxxxxxx dodatku
|
Adresa xxxxxx XXX:
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|
&xxxx; | ||||||||||||||||||||||||
&xxxx;
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x uskutečněném XXXXXX xxxxxxxx
xxxxx §30 xxxxxx x. 167/1998 Xx.
|
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|
|
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E-mail:
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Datum odeslání xxxxxxxxxxxx xxxxxxx:
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Xxxxxx x. .... xxxxxxx
Xxxxxxx x. 25 x xxxxxxxx č. 125/2006 Sb.
ROČNÍ XXXXXXX
x xxxxxxxxx x návykovými xxxxxxx, xxxxxxxxx x xxxxxxxxxx - SOUHRN
Název/jméno:
(název xxxxxxxxx osoby / xxxxxxxx
xxxxx / xxxxx x příjmení fyzické
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(xxxxx xxxxxxxxx xxxxx / xxxxx
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xxxxx §26 xxxx. 1 xxxx. x) xxxxxx x. 167/1998 Xx.
|
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Xxx, xx který xx xxxxxxx xxxxxx:
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1. Návyková xxxxx
2. Xxxxxxxxx
3. Prekursor
4. Xxxx xxxxxxx x xxxxxxx XX/XX
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Xxxx k 1.1.
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Xxx. rozdíl +/-
|
Stav x 31.12.
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Datum xxxxxxxx xxxxxxx hlášení
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ROČNÍ XXXXXXX
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Xxxxxxx č. I XXXXXX XX XXXXXXXXXX X TUZEMSKU
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|||||||||||||||||
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2
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Jméno x xxxxxxxx xxxxxxxxx xxxx xxxxxxxxxxx xxxxxx xx předkladatele ročního xxxxxxx (xxxx. xxx xxxxxxxxxx rejstříku):
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Podpis:
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Razítko:
|
1.
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2.
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Jméno x xxxxxxxx xxxxxxxxx xxxxx:
(§9 xxxx. 7 xxxx. x) xxxxxx č. 167/1998 Xx.)
|
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Xxxxxxxxxx xxxxxxx xxxxxxxxxxx xxxxxxxxx xxxxx.
Xxxxxx x. ...xxxxxxx
Xxxxxxx x. 27 x xxxxxxxx x. 125/2006 Xx.
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x xxxxxxxxx s xxxxxxxxxx xxxxxxx, xxxxxxxxx x xxxxxxxxxx
Xxxxxxx č. XX XXXXX ODBĚRATELŮM X XXXXXXXX (xxxx lékáren)
Název/jméno:
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|
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Xxxxx odběratelům x xxxxxxxx (xxxx xxxxxxx)
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(xxxxx xxxxxxxxx xxxxx / xxxxxxxx firma / xxxxx x příjmení xxxxxxx xxxxx) xxxxxx xxxxxxxxxxxx dodatku
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(xxxxx právnické xxxxx / xxxxx xxxxxxxx xxxxxx xxxxxxx xxxxx)
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Xxxxx xxxxxxxxxxx x xxxxxxxx (xxxx lékáren)
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Číslo řádku
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2. Xxxxxxxxx
3. Xxxxxxxxx
4. Xxxx xxxxxxx x xxxxxxx XX/XX
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|
|
Adresa xxxxxx XXX:
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|
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|
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Xxxxx xxxxxxxxxxx v xxxxxxxx (xxxx xxxxxxx)
|
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|
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|
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|
Množství vydané
|
Odběratel
|
Celkem xxx xxxxx látku, xxxxxxxxx, xxxxxxxxx xxxx. /*
|
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|
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|
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|
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|
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|
Adresa
|
|||||||||||||||
a
|
b
|
1
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c
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Jméno x xxxxxxxx fyzických osob xxxxxxxxxxx jednat xx xxxxxxxxxxxxx ročního xxxxxxx (xxxx. dle xxxxxxxxxx xxxxxxxxx):
|
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Xxxxxx:
|
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|
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|
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|
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|
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&xxxx; | &xxxx; | &xxxx; |
&xxxx; | &xxxx;
Xxxxx xxxxx přílohy x. XX x xxxxxxx xxxxxxx xxxxxx:
|
&xxxx; |
&xxxx; | &xxxx; | &xxxx; |
/* xxxxxxx uvedená xx xxxxxxx 5 "Celkem xxx ..." se xxxxxxx do Ročního xxxxxxx x zacházení x xxxxxxxxxx xxxxxxx, xxxxxxxxx a prekursory - XXXXXX - xxxxxxx 2
Xxxxxxxxxx xxxxxxx xxxxxxxxxxx xxxxxxxxx čarou.
Strana x. ...xxxxxxx
Příloha x. 28 x vyhlášce č. 125/2006 Xx.
XXXXX XXXXXXX
x xxxxxxxxx x návykovými xxxxxxx, xxxxxxxxx x xxxxxxxxxx
Xxxxxxx x. III XXXXXX XXXXXX
&xxxx;
Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / xxxxxxxx xxxxx / xxxxx x xxxxxxxx xxxxxxx xxxxx) xxxxxx xxxxxxxxxxxx xxxxxxx
|
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|
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Xxxxxx xxxxxx XXX:
(xxxxx xxxxxxxxx osoby / xxxxx
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|
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|
||||||||||||||||||
&xxxx;
XXXXX HLÁŠENÍ
o zacházení x návykovými xxxxxxx, xxxxxxxxx x xxxxxxxxxx
Xxxxxxx x. III XXXXXX XXXXXX
|
|||||||||||||||||||||
&xxxx;
Xxxxxxxxxxxxx xxxxx (XX):
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|
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|
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|
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&xxxx;
Xxxxxx xxxxxx
|
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Xxxxx xxxxx
|
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1. Xxxxxxxx látka
2. Xxxxxxxxx
3. Xxxxxxxxx
4. Xxxx xxxxxxx s obsahem XX/XX
|
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Xxxxx xxxxxxxx
|
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Xxxxxx
|
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|
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Xxxxxxxx (xxxxx při xxxxxxxxxx xxxxxxxxxxx xxxxx)
|
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&xxxx;
Xxxxxxxxxxxxx
(xxxxxxxxxx)
|
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Xxxxxxxx /*
|
Normované
|
%
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Skutečné
|
%
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Strana x. ..... hlášení
Název/jméno:
(název xxxxxxxxx xxxxx / xxxxxxxx firma / xxxxx a xxxxxxxx xxxxxxx xxxxx) včetně xxxxxxxxxxxx dodatku
|
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Adresa xxxxxx XXX:
(xxxxx právnické xxxxx / xxxxx
xxxxxxxx xxxxxx xxxxxxx xxxxx)
|
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|
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&xxxx; | |||||||||||||||||||||
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|
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|
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2. Xxxxxxxxx
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4. Jiný xxxxxxx x xxxxxxx XX/XX
|
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|
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|
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(xxxxxxxxxx)
|
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(xxxxx xxxxxxxxx osoby / xxxxxxxx xxxxx / xxxxx x xxxxxxxx xxxxxxx xxxxx) xxxxxx xxxxxxxxxxxx dodatku
|
|
Adresa včetně XXX:
(xxxxx xxxxxxxxx xxxxx / místa
trvalého xxxxxx xxxxxxx xxxxx)
|
&xxxx;
|
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&xxxx; | |||||||||||||||||||||
&xxxx;
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|
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|
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1. Xxxxxxxx látka
2. Xxxxxxxxx
3. Prekursor
4. Xxxx xxxxxxx s xxxxxxx XX/XX
|
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|
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|
&xxxx;
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|
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Xxxxxxxx (xxxxx xxx překročení xxxxxxxxxxx xxxxx)
|
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&xxxx;
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(xxxxxxxxxx)
|
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|
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|
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2
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3
|
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4
|
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5
|
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6
|
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Xxxxx x xxxxxxxx xxxxxxxxx xxxx oprávněných xxxxxx xx xxxxxxxxxxxxx xxxxxxx xxxxxxx (xxxx. xxx xxxxxxxxxx rejstříku):
|
Podpis:
|
Razítko:
|
1.
|
|
|
2.
|
|
|
|
||
Jméno x xxxxxxxx xxxxxxxxx xxxxx:
(§9 xxxx. 7 xxxx. x) zákona x. 167/1998 Sb.)
|
Podpis:
|
|
Počet xxxxx xxxxxxx č. III x xxxxxxx xxxxxxx xxxxxx:
|
&xxxx; | |
&xxxx; | &xxxx; | &xxxx; |
/* hodnota xxxxxxx xx xxxxxxx 2 "Xxxxxx uskutečněná" xx xxxxxxx do Xxxxxxx xxxxxxx o xxxxxxxxx x návykovými látkami, xxxxxxxxx x xxxxxxxxxx - XXXXXX - xxxxxxx 4
Nevyplněné kolonky xxxxxxxxxxx xxxxxxxxx xxxxx.
Xxxxxx x. ........... hlášení
Xxxxxxx x. 29 x xxxxxxxx x. 125/2006 Xx.
XXXXX XXXXXXX
x xxxxxxxxx x xxxxxxxxxx xxxxxxx, přípravky a xxxxxxxxxx
Xxxxxxx x. XX XXXXXX - XXXXX XXXXXXXXX XXXXXXX
&xxxx;
Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / xxxxxxxx xxxxx / xxxxx x xxxxxxxx fyzické xxxxx) xxxxxx xxxxxxxxxxxx xxxxxxx
|
&xxxx;
|
&xxxx;
Xxxxxx xxxxxx XXX:
(xxxxx xxxxxxxxx xxxxx / xxxxx
xxxxxxxx xxxxxx xxxxxxx xxxxx)
|
&xxxx;
|
||||||||||||||||
&xxxx;
XXXXX XXXXXXX
x zacházení x xxxxxxxxxx xxxxxxx, xxxxxxxxx a xxxxxxxxxx
Xxxxxxx x. IV XXXXX XXXXXXXXX PODNIKU
|
|||||||||||||||||||
Identifikační číslo (XX):
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxx, za xxxxx xx xxxxxxx xxxxxx:
|
&xxxx;
|
||||||||
&xxxx;
|
|||||||||||||||||||
&xxxx;
Xxxxx xxxxxxxxx xxxxxxx
|
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&xxxx;
Xxxxx xxxxx
|
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Xxxxxxx xxxxxxxx, návyková xxxxx, xxxxxxxxx
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&xxxx;
Xxxxx xxxxxxxx návykové xxxxx, přípravku, xxxxxxxxxx, xxxxxx xxxxxxxxxx xxxxxxx
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&xxxx;
Xxxxxxxx
|
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&xxxx;
Xxxxx
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&xxxx;
Xxxxxxxx xxxxxx xx xxxxxx
(x xxxxxxx xxxx mililitrech)
|
Množství xxxxxx xx
|
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Xxxxxx /*
|
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&xxxx;
Xxxx XX, XX
|
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XX-XX
XX-XX
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Xxxxxxxxx
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Xxxxxx xxxxxxx
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&xxxx;
Xxxxx
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&xxxx;
XXX
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&xxxx;
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&xxxx;
x
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&xxxx;
1
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&xxxx;
2
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3
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4
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&xxxx;
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&xxxx;
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7
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x
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x
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Xxxxxx x. ...... hlášení
Název/jméno:
(název xxxxxxxxx xxxxx / xxxxxxxx xxxxx / xxxxx a příjmení xxxxxxx xxxxx) včetně xxxxxxxxxxxx xxxxxxx
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&xxxx;
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Xxxxxx xxxxxx XXX:
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Výdej xxxxxxxxx xxxxxxx
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Xxxxx xxxxxxxx xxxxxxxx látky, xxxxxxxxx, xxxxxxxxxx, xxxxxx xxxxxxxxxx výrobku
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Poznámka
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Název
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Množství xxxxxx xx xxxxxx
(x gramech xxxx xxxxxxxxxxx)
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Xxxxxxxx vydané xx
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Xxxxxx /*
|
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|
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Xxxxxx výrobku
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Vývoj
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OTK
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Strana č. ...... xxxxxxx
&xxxx;
Xxxxx/xxxxx:
(xxxxx právnické xxxxx / xxxxxxxx xxxxx / jméno x příjmení xxxxxxx xxxxx) včetně xxxxxxxxxxxx xxxxxxx
|
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|
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|
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|
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Xxxxx vlastnímu xxxxxxx
|
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Xxxxx xxxxx
|
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Xxxxxxx xxxxxxxx, xxxxxxxx xxxxx, xxxxxxxxx
|
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Xxxxx xxxxxxxx xxxxxxxx xxxxx, přípravku, xxxxxxxxxx, xxxxxx xxxxxxxxxx xxxxxxx
|
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Xxxxxxxx
|
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|
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Xxxxxxxx xxxxxx xx xxxxxx
(x xxxxxxx xxxx xxxxxxxxxxx)
|
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Xxxxxxxx xxxxxx xx
|
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Xxxxxx /*
|
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Xxxx OL, XX
|
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|
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Xxxxxxxxx
|
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Xxxxxx xxxxxxx
|
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|
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|
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|
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x
|
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1
|
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2
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3
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&xxxx;
4
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&xxxx;
5
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&xxxx;
6
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&xxxx;
7
|
&xxxx;
x
|
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|
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|
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|
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Xxxxx a příjmení xxxxxxxxx xxxx oprávněných xxxxxx xx xxxxxxxxxxxxx xxxxxxx xxxxxxx (xxxx. xxx xxxxxxxxxx rejstříku):
|
Podpis:
|
Razítko:
|
1.
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2.
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||
Jméno x xxxxxxxx xxxxxxxxx xxxxx:
(§9 xxxx. 7 xxxx. x) xxxxxx x. 167/1998 Sb.)
|
Podpis:
|
|
Počet xxxxx xxxxxxx č. XX x ročnímu xxxxxxx xxxxxx:
|
&xxxx; | |
&xxxx; | &xxxx; | &xxxx; |
/* hodnota xxxxxxx xx xxxxxxx 7 "Xxxxxx" xx xxxxxxx xx Xxxxxxx xxxxxxx o xxxxxxxxx x xxxxxxxxxx xxxxxxx, xxxxxxxxx x prekursory - XXXXXX - xxxxxxx 6
Xxxxxxxxxx xxxxxxx xxxxxxxxxxx xxxxxxxxx xxxxx.
Xxxxxx x. ...... xxxxxxx
Xxxxxxx x. 30 x xxxxxxxx č. 125/2006 Sb.
ROČNÍ HLÁŠENÍ
o xxxxxxxxx x návykovými xxxxxxx, přípravky x xxxxxxxxxx
Xxxxxxx č. X XXXXXX - DETAIL XXXXX ZÁSOB
Název/jméno:
(název xxxxxxxxx xxxxx / obchodní xxxxx / xxxxx x xxxxxxxx xxxxxxx xxxxx) xxxxxx odlišujícího xxxxxxx
|
&xxxx;
|
&xxxx;
Xxxxxx xxxxxx XXX:
(xxxxx xxxxxxxxx osoby / xxxxx
xxxxxxxx xxxxxx fyzické xxxxx)
|
&xxxx;
|
|||||||||||||||
&xxxx;
XXXXX HLÁŠENÍ
o zacházení x návykovými xxxxxxx, xxxxxxxxx a prekursory
Příloha x. X VÝROBA - XXXXXX STAVŮ XXXXX
|
||||||||||||||||||
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Xxxxxxxxxxxxx xxxxx (XX):
|
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|
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|
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|
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|
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|
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|
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|
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Xxx, xx xxxxx xx xxxxxxx podává:
|
|
|||||||
Detail stavů xxxxx
xxxxxxxxxx látek a xxxxxxxxxx
|
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&xxxx;
Xxxxx xxxxx
|
&xxxx;
Xxxxx xxxxxxxx xxxxx, xxxxxxxxxx
|
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Xxxxx xxxxxxxx
|
&xxxx;
Xxxx x 1.1.
|
Stav x 31.12.
|
||||||||||||||
&xxxx;
X xxxxxxxxxxxx výrobě
|
Poznámka (xxxxx xxxxx)
|
&xxxx;
Xx xxxxxxxx xxxxxx /*
|
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X xxxxxxxxxxxx xxxxxx
|
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Xxxxxxxx (xxxxx xxxxx)
|
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Xx xxxxxxxx celkem /*
|
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|
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x
|
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x
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1
|
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Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / xxxxxxxx xxxxx / xxxxx a xxxxxxxx xxxxxxx osoby) xxxxxx xxxxxxxxxxxx xxxxxxx
|
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|
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Xxxxxx xxxxxx XXX:
(xxxxx xxxxxxxxx xxxxx / xxxxx
xxxxxxxx pobytu xxxxxxx xxxxx)
|
&xxxx;
|
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|
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Xxxxx xxxxx
|
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Xxxxx xxxxxxxx xxxxx, xxxxxxxxxx
|
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Xxxxx xxxxxxxx
|
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|
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Xxxx x 31.12.
|
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|
Poznámka (xxxxx šarží)
|
Na skladech xxxxxx /*
|
V rozpracované xxxxxx
|
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Xxxxxxxx (xxxxx xxxxx)
|
&xxxx;
Xx xxxxxxxx xxxxxx /*
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Strana x. ....... xxxxxxx
&xxxx;
Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / xxxxxxxx xxxxx / xxxxx x xxxxxxxx xxxxxxx xxxxx) xxxxxx xxxxxxxxxxxx xxxxxxx
|
&xxxx;
|
&xxxx;
Xxxxxx xxxxxx XXX:
(xxxxx právnické osoby / xxxxx
xxxxxxxx xxxxxx xxxxxxx osoby)
|
|
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Detail xxxxx xxxxx
xxxxxxxxxx xxxxx a xxxxxxxxxx
|
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&xxxx;
Xxxxx xxxxx
|
&xxxx;
Xxxxx xxxxxxxx xxxxx, xxxxxxxxxx
|
&xxxx;
Xxxxx jednotka
|
Stav x 1.1.
|
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Xxxx x 31.12.
|
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&xxxx;
X xxxxxxxxxxxx xxxxxx
|
&xxxx;
Xxxxxxxx (xxxxx šarží)
|
Na skladech xxxxxx /*
|
V xxxxxxxxxxxx xxxxxx
|
&xxxx;
Xxxxxxxx (xxxxx xxxxx)
|
&xxxx;
Xx xxxxxxxx celkem /*
|
|||||||||||||
&xxxx;
|
&xxxx;
x
|
&xxxx;
x
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&xxxx;
1
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&xxxx;
2
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
6
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&xxxx;
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|
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|
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Xxxxx x příjmení xxxxxxxxx xxxx oprávněných xxxxxx xx xxxxxxxxxxxxx ročního xxxxxxx (xxxx. xxx xxxxxxxxxx rejstříku):
|
Podpis:
|
Razítko:
|
1.
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2.
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||
Jméno a xxxxxxxx odpovědné osoby:
(§9 xxxx. 7 písm. x) xxxxxx č. 167/1998 Xx.)
|
&xxxx;
Xxxxxx:
|
&xxxx; |
&xxxx; | &xxxx; | &xxxx; |
&xxxx; | &xxxx;
Xxxxx listů xxxxxxx č. V x xxxxxxx hlášení xxxxxx:
|
&xxxx; |
&xxxx; | &xxxx; | &xxxx; |
/* xxxxxxx uvedené xx xxxxxxx 3 x 6 "Xxxxxx" xx xxxxxxxx do Xxxxxxx hlášení o xxxxxxxxx x xxxxxxxxxx xxxxxxx, xxxxxxxxx a xxxxxxxxxx - XXXXXX - xxxxxxx 1 x 12
Xxxxxxxxxx xxxxxxx xxxxxxxxxxx xxxxxxxxx čarou.
Strana x. ........... xxxxxxx
Xxxxxxx č. 31 x xxxxxxxx x. 125/2006 Xx.
XXXXX HLÁŠENÍ
osob xxxxxxxxxxxxx xxxxxxx o xxxxxx, xxxxxx x xxxxx xxxxx xxxxxxxx xxxxx
&xxxx;
Xxxxx xxxxxxx:
|
&xxxx;
|
&xxxx;
Xxxxxx lékárny:
včetně XXX
|
&xxxx;
|
||||||||||
&xxxx;
XXXXX XXXXXXX osob xxxxxxxxxxxxx xxxxxxx
x příjmu, xxxxxx a xxxxx xxxxx omamných xxxxx xxxxxxxxx v xxxxxxx x. 1 zákona x. 167/1998 Sb. x psychotropních xxxxx xxxxxxxxx x příloze x. 5 xxxxxx x. 167/1998 Xx. x xxxxxxxxx x xxxxxx obsahem (xxxxx §27 xxxxxx č. 167/1998 Xx.)
|
|||||||||||||
&xxxx;
Xxxxxxxxxxxxx číslo (XX):
|
&xxxx;
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&xxxx;
|
&xxxx;
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&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxx, za který xx xxxxxxx xxxxxx:
|
&xxxx;
|
||
&xxxx;
|
&xxxx;
Xxxxx xxxxx
|
&xxxx;
Xxxxx xxxxxxxxx xxxx xxxxxxxx xxxxx
|
&xxxx;
Xxxxx xxxxxxxx
|
&xxxx;
Xxxx x
1.1.
|
&xxxx;
XXXXXX
|
&xxxx;
|
&xxxx;
|
&xxxx;
XXXXXX
|
&xxxx;
|
&xxxx;
|
&xxxx;
Xxx.
xxxxxx
+/-
|
&xxxx;
Xxxx x
31.12.
|
||
&xxxx;
Xx dodavatelů
|
Z xxxxxxx
|
&xxxx;
Xxxxxxx a xxxxxxx
|
&xxxx;
Xxxxxxxx
|
&xxxx;
Xxxxxxxxxxx (xxxxxxxxx)
|
&xxxx;
Xxxxxxxxxxxx xxxxxxx
|
&xxxx;
Xxxxxxxxxx
|
&xxxx;
Xxxxxxxxx zkoušky
|
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Strana x. ....... xxxxxxx
&xxxx;
Xxxxx xxxxxxx:
|
&xxxx;
|
&xxxx;
Xxxxxx xxxxxxx:
xxxxxx XXX
|
&xxxx;
|
||||||||||
&xxxx;
XXXXX XXXXXXX xxxx xxxxxxxxxxxxx xxxxxxx
|
|||||||||||||
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|
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Xxxxx xxxxx
|
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Xxxxx xxxxxxxxx xxxx xxxxxxxx xxxxx
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Xxxxx xxxxxxxx
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Xxxxxxx č. 33 x xxxxxxxx č. 125/2006 Sb.
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x xxxxxx xxxxxxxxx xxxxx
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Xxxxxx x. ...........hlášení
Xxxxxxx x. 35 x vyhlášce č. 125/2006 Sb.
ROČNÍ HLÁŠENÍ
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Xxxxxxx x. I XXXXXX XXXXXXXXX XXXXXXXXXX MNOŽSTVÍ
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Xxxxxx č.............hlášení
Xxxxxxx x. 36 x xxxxxxxx x. 125/2006 Xx.
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Číslo xxxxx
|
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Xxxxx pomocné látky xxxxx xxxxxxx nařízení Xxxx (XX) č. 111/2005
|
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|
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|
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|
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Xxxxxxx dovezené xxxxxxxx xx xxx, xx xxxxx se xxxxxxx xxxxxx
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Xxxxxxx množství xxxxxx xxx xxxxxxx potřebu
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|
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E-mail:
|
Telefon:
|
Fax:
|
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|
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|
Razítko:
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Počet xxxxx ročního hlášení xxxxxx:
|
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|
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Počet xxxxx těchto xxxxxx:
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↓ xxxxx xxxx x xxxxxxx xxxxxxx xxxxxxx xx xxxxx se xxxxxxxx x xxxxxxx
Xxxxxxxxxx xxxxxxx proškrtněte xxxxxxxxx xxxxx.
Xxxxxx x. ...........xxxxxxx
Xxxxxxx x. 37 x xxxxxxxx č. 125/2006 Xx.
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|
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ROČNÍ XXXXXXX
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Xxxxx pomocné xxxxx xxxxx přílohy xxxxxxxx Xxxx (ES) č. 111/2005
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Xxxxx xxxxxxxx
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Xxxx, xx xxxxx xxxx pomocná xxxxx dovezena
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Množství xxxxxxxx xxxxxxx xxxxx
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Xxxxxxx množství xxx xxxxx xxxxxxxx xxxxx
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Xxxxxx č. ....... xxxxxxx
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Xxxxx/xxxxx:
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Xxxxxx xxxxxx PSČ:
(sídla právnické xxxxx / xxxxx
xxxxxxxx xxxxxx xxxxxxx xxxxx)
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XXXXX XXXXXXX x dovozu xxxxxxxxx látek
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Číslo xxxxx
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Xxxxx xxxxxxx xxxxx xxxxx xxxxxxx xxxxxxxx Rady (XX) č. 111/2005
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Xxxxx xxxxxxxx
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&xxxx;
Xxxx, xx xxxxx byla xxxxxxx xxxxx xxxxxxxx
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Xxxxxxxx xxxxxxxx pomocné xxxxx
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Xxxxxxx xxxxxxxx xxx xxxxx xxxxxxxx látku
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xxxxxxxx xxxxxx xxxxxxx xxxxx)
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XXXXX XXXXXXX x xxxxxx pomocných xxxxx
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Xxxxx xxxxxxx xxxxx xxxxx přílohy xxxxxxxx Xxxx (XX) č. 111/2005
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Xxxx, xx xxxxx xxxx xxxxxxx látka xxxxxxxx
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Xxxxxx:
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Xx správnost xxxxxxxx:
(xxxxx x xxxxxxxx xxxxxxxxx xxxxx)
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Xxxxxx:
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Xxxxx listů xxxx xxxxxxx xxxxxxx xxxxxxx xxxxxx:
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&xxxx;
Xxxxx odeslání xxxxxxx xxxxxxx: ...............................
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&xxxx; | &xxxx; | &xxxx; |
↑ xxxxx xxxx x xxxxxxx xxxxxxx ukazuje xx xxxxx se xxxxxxxx v xxxxxxx
Xxxxxxxxxx xxxxxxx xxxxxxxxxxx xxxxxxxxx xxxxx.
Xxxxxx x.............xxxxxxx
Xxxxxxx x. 38 x xxxxxxxx x. 125/2006 Xx.
XXXXX HLÁŠENÍ
o xxxxxx pomocných xxxxx xxxxxxxxx x xxxxxxxxx 2
Xxxxxxx x. XX XXXXXX XXXXXXXXXXXXXX XXXXXXXX XXX XXXXXXX XXXXX
&xxxx;
Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / xxxxxxxx xxxxx / xxxxx a xxxxxxxx xxxxxxx osoby) xxxxxx xxxxxxxxxxxx dodatku
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Adresa xxxxxx XXX:
(xxxxx xxxxxxxxx xxxxx / xxxxx
xxxxxxxx xxxxxx xxxxxxx xxxxx)
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&xxxx;
XXXXX XXXXXXX
x xxxxxx xxxxxxxxx xxxxx xxxxxxxxx x xxxxxxxxx 2
Xxxxxxx č. II XXXXXX XXXXXXXXXXXXXX XXXXXXXX XXX XXXXXXX XXXXX
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Xxxxxxxxxxxxx xxxxx (IČ):
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Číslo xxxxx
|
&xxxx;
Xxxxx xxxxxxx xxxxx xxxxx xxxxxxx xxxxxxxx Xxxx (XX) č. 111/2005
|
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Xxxxx jednotka
|
Účel xxxxxxx spotřeby (xxxxxx xxxxxxxxxxx)
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Xxxxxxxx spotřebované xxxxxxx xxxxx
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Xxxxxxx xxxxxxxx xxx xxxxx xxxxxxxx látku
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(xxxxx xxxxxxxxx xxxxx / místa
trvalého xxxxxx xxxxxxx osoby)
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ROČNÍ XXXXXXX x xxxxxx xxxxxxxxx xxxxx
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Xxxxx xxxxxxx xxxxx xxxxx xxxxxxx xxxxxxxx Xxxx (XX) č. 111/2005
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Xxxxx jednotka
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Účel xxxxxxx xxxxxxxx (xxxxxx xxxxxxxxxxx)
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Xxxxxxxx xxxxxxxxxxxx xxxxxxx xxxxx
|
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Xxxxxxx xxxxxxxx pro xxxxx xxxxxxxx látku
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Název/jméno:
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Xxxxxx včetně XXX:
(xxxxx xxxxxxxxx xxxxx / xxxxx
xxxxxxxx xxxxxx xxxxxxx xxxxx)
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XXXXX HLÁŠENÍ x xxxxxx xxxxxxxxx xxxxx
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Xxxxx xxxxx
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Xxxxx xxxxxxx látky xxxxx xxxxxxx xxxxxxxx Xxxx (XX) č. 111/2005
|
Měrná xxxxxxxx
|
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Xxxx vlastní xxxxxxxx (xxxxxx podrobnosti)
|
Množství xxxxxxxxxxxx xxxxxxx xxxxx
|
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Xxxxxxx xxxxxxxx xxx tutéž pomocnou xxxxx
↑
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Xxxxx a xxxxxxxx xxxxxxxxx osob xxxxxxxxxxx xxxxxx xx xxxxxxxxxxxxx xxxxxxx xxxxxxx (xxxx. xxx xxxxxxxxxx rejstříku):
|
Podpis:
|
Za xxxxxxxxx odpovídá:
(jméno x xxxxxxxx xxxxxxxxx xxxxx)
|
&xxxx;
Xxxxxx:
|
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&xxxx;
1.
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2.
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Xxxxxxx:
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Xxxxx xxxxx xxxx xxxxxxx xxxxxxx xxxxxxx xxxxxx:
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&xxxx;
Xxxxx xxxxxxxx xxxxxxx xxxxxxx: ...............................
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&xxxx; | &xxxx; |
&xxxx; | &xxxx; | &xxxx; |
↑ tento znak x záhlaví xxxxxxx xxxxxxx xx vazbu xx xxxxxxxx x xxxxxxx
Xxxxxxxxxx kolonky proškrtněte xxxxxxxxx xxxxx.
Xxxxxx x.............xxxxxxx
Příloha č. 39 x xxxxxxxx č. 125/2006 Xx.
XXXXX XXXXXXX
x xxxxxxxxx xxxx xxxxxx x xxxxxx
&xxxx;
XXXXXXXXX XXXXXXXXXXX XXX
|
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Xxxxx:
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Xxxxxx (ulice, xxxxx, XXX):
|
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|
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&xxxx;
XXXXX HLÁŠENÍ
o pěstování xxxx setého x xxxxxx
xxxxx §43 odst. 6 písm. x) xxxxxx č. 167/1998 Xx.
|
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Xxx, za který xx xxxxxxx xxxxxx:
|
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|
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&xxxx;
|
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Xxxxxxxx xxxxxxxx makoviny / xxxxxx
(x xx) xx xxxxxxx rok
|
Rozloha xxxxxxx (x ha), xx xxxxx xxxx xxx xxxx/xxxxxx x xxxxxxxx xxxx xxxxxxxxx
|
&xxxx;
Xxxxx xxxxxxxxx
|
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Xxxxx
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|
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Xxx xxxx
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Xxxxxx
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|
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Xxxxxxx xxxxxxxxx (jméno, xxxxxxxx a xxxxx):
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
X-xxxx:
|
&xxxx;
Xxxxxxx:
|
||
&xxxx;
|
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|
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Xx xxxxx (xxxxx, příjmení x xxxxx):
|
&xxxx;
Xxxxxx:
|
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X-xxxx:
|
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Xxxxxxx:
|
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|
&xxxx;
|
Xxxxxxx: Datum:
Nevyplněné xxxxxxx xxxxxxxxxxx xxxxxxxxx xxxxx.
Xxxxxxx č. 40 x xxxxxxxx x. 125/2006 Sb.
OSETÉ XXXXXX X XXXXXX ODHAD
pěstování xxxx xxxxxx a xxxxxx
&xxxx;
XXXXXXXXX XXXXXXXXXXX CEL
|
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Odbor:
|
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Adresa (xxxxx, xxxxx, XXX):
|
&xxxx;
|
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&xxxx;
XXXXX XXXXXX X XXXXXX XXXXX
xxxxxxxxx xxxx setého x konopí
podle §43 xxxx. 6 písm. x) xxxxxx x. 167/1998 Xx.
|
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&xxxx;
|
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&xxxx;
X 31.5. xxxx:
|
&xxxx;
|
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&xxxx;
|
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&xxxx;
|
&xxxx;
Xxxxxxxx xxxxxxx xxxxxxx (x ha), xx xxxxxxx xxxx xxx xxxx / xxxxxx xxxxxx x xxxxx xxxx x 31.5.
|
Odhad xxxxxxx xxxxxxx (x xx), na xxxxx xxxxx mák xxxx / xxxxxx xxxxxxxxx x příštím kalendářním xxxx
|
&xxxx;
Xxxxx xxxxxxxxx
|
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Xxx setý
|
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Konopí
|
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Hlášení xxxxxxxxx (xxxxx, xxxxxxxx x xxxxx):
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
X-xxxx:
|
&xxxx;
Xxxxxxx:
|
||
&xxxx;
|
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|
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|
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&xxxx;
Xx odbor (xxxxx, xxxxxxxx x xxxxx):
|
&xxxx;
Xxxxxx:
|
&xxxx;
X-xxxx:
|
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Xxxxxxx:
|
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|
&xxxx;
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&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
Xxxxxxx: Xxxxx:
Xxxxxxxxxx xxxxxxx xxxxxxxxxxx souvislou čarou.
Příloha x. 41 x xxxxxxxx č. 125/2006 Xx.
XXXXX DOVOZU
návykových xxxxx x přípravků
Název/jméno:
(název xxxxxxxxx osoby / xxxxxxxx firma / xxxxx x xxxxxxxx xxxxxxx osoby) xxxxxx xxxxxxxxxxxx xxxxxxx
|
&xxxx;
|
&xxxx;
Xxxxxx xxxxxx XXX:
(xxxxx právnické xxxxx / místa xxxxxxxx xxxxxx fyzické xxxxx)
|
&xxxx;
|
||||||||||||
&xxxx;
XXXXX XXXXXX
xxxxxxxxxx xxxxx x xxxxxxxxx
xxxxx §26 xxxx. 1 písm. x) xxxxxx x. 167/1998 Xx.
|
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&xxxx;
Xxxxxxxxxxxxx xxxxx (XX):
|
&xxxx; | &xxxx;
|
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|
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|
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|
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|
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Xxx, xx xxxxx xx xxxxx podává:
|
|
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|
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Název xxxxxxxx xxxxx nebo xxxxxxxxx
|
&xxxx;
Xxxxx xxxxxxxx uvést x x (x substance) xxxx x xxxxx xxxxxx (x XXXX)
|
&xxxx;
Xxxx xxxxxx
|
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&xxxx;
1
|
&xxxx;
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|
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|
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&xxxx;
1x
|
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1x *)
|
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Strana x. ...... xxxxxx xxxxxx
&xxxx;
Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / xxxxxxxx xxxxx / xxxxx x příjmení xxxxxxx xxxxx) včetně xxxxxxxxxxxx xxxxxxx
|
&xxxx;
|
&xxxx;
Xxxxxx xxxxxx XXX:
(xxxxx xxxxxxxxx xxxxx / xxxxx xxxxxxxx xxxxxx fyzické osoby)
|
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ODHAD XXXXXX
|
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&xxxx; | |||||||||||||||
&xxxx;
Xxxxx xxxxxxxx xxxxx xxxx přípravku
|
Odhad xxxxxxxx xxxxx v x (x substance) xxxx x xxxxx balení (x XXXX)
|
&xxxx;
Xxxx dovozu
|
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|
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|
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|
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&xxxx;
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
&xxxx;
|
&xxxx;
|
&xxxx;
|
||||||||||||
&xxxx;
|
&xxxx;
|
&xxxx;
|
&xxxx;
|
Xxxxxx x. ...... xxxxxx xxxxxx
&xxxx;
Xxxxx/xxxxx:
(xxxxx právnické xxxxx / obchodní xxxxx / jméno x příjmení fyzické xxxxx) xxxxxx xxxxxxxxxxxx xxxxxxx
|
&xxxx;
|
&xxxx;
Xxxxxx xxxxxx XXX:
(xxxxx xxxxxxxxx osoby / xxxxx xxxxxxxx pobytu xxxxxxx xxxxx)
|
&xxxx;
|
||||||||||||
&xxxx;
XXXXX XXXXXX
|
|||||||||||||||
&xxxx; | |||||||||||||||
&xxxx;
Xxxxx xxxxxxxx xxxxx xxxx xxxxxxxxx
|
&xxxx;
Xxxxx množství uvést x x (u xxxxxxxxx) xxxx x xxxxx xxxxxx (x XXXX)
|
&xxxx;
Xxxx xxxxxx
|
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&xxxx;
1
|
&xxxx;
2
|
&xxxx;
3
|
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&xxxx;
1x
|
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1x *)
|
&xxxx;
|
&xxxx;
|
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|
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|
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&xxxx;
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&xxxx;
Xxxxx x xxxxxxxx fyzických xxxx xxxxxxxxxxx jednat xx předkladatele odhadu xxxxxx (xxxx. xxx xxxxxxxxxx xxxxxxxxx):
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Xxxxxx:
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Xxxxxx:
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Xxxxxxx:
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&xxxx;
1.
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&xxxx;
2.
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&xxxx;
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Xxxxx, příjmení x xxxxx odpovědné xxxxx:
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Xxxxxx:
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&xxxx;
Xxxxxx:
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&xxxx;
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&xxxx;
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X-xxxx:
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Xxxxxxx:
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Xxx:
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&xxxx;
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&xxxx;
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&xxxx;
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&xxxx;
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Xxxxx xxxxxxxx xxxxxx xxxxxx:
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&xxxx;
Xxxxx xxxxx odhadu xxxxxx xxxxxx:
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&xxxx; |
&xxxx; | &xxxx; | &xxxx; |
&xxxx;
Xxxxxxx:
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&xxxx; | &xxxx; |
&xxxx; | &xxxx; | &xxxx; |
*) Xx xxxxxxx 1x xx xxxxx xxxxxxxx látka xxxxxxxx v přípravku xxxxxxxx xx sloupci 1x.
Xxxxxxxxxx xxxxxxx proškrtněte xxxxxxxxx čarou.
Strana x. ........... odhadu xxxxxx
Xxxxxxx č. 42 x xxxxxxxx x. 125/2006 Sb.
ODHAD VÝROBY
návykových xxxxx, xxxxxxxxx a xxxxxxxxxx
&xxxx;
Xxxxx/xxxxx:
(xxxxx právnické xxxxx / obchodní xxxxx / xxxxx a xxxxxxxx xxxxxxx xxxxx) xxxxxx xxxxxxxxxxxx dodatku
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Adresa xxxxxx XXX:
(xxxxx právnické xxxxx / místa xxxxxxxx xxxxxx xxxxxxx xxxxx)
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&xxxx;
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&xxxx;
XXXXX VÝROBY
návykových xxxxx, xxxxxxxxx x xxxxxxxxxx
xxxxx §26 xxxx. 1 xxxx. b) xxxxxx x. 167/1998 Xx.
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&xxxx;
Xxxxxxxxxxxxx xxxxx (XX):
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Xxx, xx xxxxx se xxxxx xxxxxx:
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&xxxx;
Xxxxxxxx xxxxx, přípravek xxxx xxxxxxxxx
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&xxxx;
Xxxxx vyrobeného xxxxxxxx x gramech, xxxxxxxxxxx xxxx x xxxxx xxxxxx
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&xxxx;
Xxxxxxxx v xxxxxxx xxxxxxxx látky xxxx xxxxxxxxxx x xxxxxxxx xxxxxxxxx množství xxxxxxxxx včetně xxxxxxxxx xxxxx
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&xxxx;
Xxxx xxxxxx
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&xxxx;
1
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&xxxx;
1x
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&xxxx;
1x*)
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2
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4
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Xxxxxx č. ...... xxxxxx xxxxxx
&xxxx;
Xxxxx/xxxxx:
(xxxxx xxxxxxxxx xxxxx / xxxxxxxx firma / xxxxx a příjmení xxxxxxx xxxxx) včetně xxxxxxxxxxxx dodatku
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Adresa xxxxxx XXX:
(xxxxx xxxxxxxxx osoby / xxxxx trvalého xxxxxx xxxxxxx osoby)
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ODHAD XXXXXX
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&xxxx;
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&xxxx;
Xxxxxxxx xxxxx, xxxxxxxxx xxxx xxxxxxxxx
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&xxxx;
Xxxxx xxxxxxxxxx xxxxxxxx x gramech, xxxxxxxxxxx xxxx v xxxxx xxxxxx
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&xxxx;
Xxxxxxxx x xxxxxxx návykové látky xxxx prekursoru v xxxxxxxx xxxxxxxxx xxxxxxxx xxxxxxxxx včetně výrobních xxxxx
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&xxxx;
Xxxx výroby
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Strana x. ...... odhadu výroby
Název/jméno:
(název xxxxxxxxx xxxxx / xxxxxxxx firma / xxxxx x xxxxxxxx xxxxxxx xxxxx) xxxxxx xxxxxxxxxxxx xxxxxxx
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&xxxx;
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&xxxx;
Xxxxxx včetně XXX:
(xxxxx xxxxxxxxx xxxxx / xxxxx xxxxxxxx xxxxxx xxxxxxx osoby)
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ODHAD XXXXXX
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&xxxx;
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&xxxx;
Xxxxxxxx látka, xxxxxxxxx xxxx xxxxxxxxx
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&xxxx;
Xxxxx xxxxxxxxxx xxxxxxxx v xxxxxxx, xxxxxxxxxxx xxxx x xxxxx xxxxxx
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&xxxx;
Xxxxxxxx x xxxxxxx xxxxxxxx xxxxx xxxx xxxxxxxxxx x xxxxxxxx vyrobeném xxxxxxxx xxxxxxxxx xxxxxx výrobních xxxxx
|
&xxxx;
Xxxx xxxxxx
|
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&xxxx;
1
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&xxxx;
1x
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&xxxx;
1x*)
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2
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3
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4
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Xxxxx x xxxxxxxx fyzických xxxx xxxxxxxxxxx xxxxxx xx xxxxxxxxxxxxx xxxxxx xxxxxx (xxxx. dle obchodního xxxxxxxxx):
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxx:
|
&xxxx;
Xxxxxxx:
|
||
&xxxx;
1.
|
&xxxx;
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&xxxx;
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&xxxx;
|
||
&xxxx;
2.
|
&xxxx;
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&xxxx;
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&xxxx;
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||
&xxxx;
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Xxxxx, xxxxxxxx a xxxxx xxxxxxxxx xxxxx:
|
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Xxxxxx:
|
&xxxx;
Xxxxxx:
|
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&xxxx;
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&xxxx;
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&xxxx;
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X-xxxx:
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&xxxx;
Xxxxxxx:
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&xxxx;
Xxx:
|
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&xxxx;
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|
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Xxxxx xxxxxxxx xxxxxx xxxxxx:
|
&xxxx;
Xxxxx xxxxx xxxxxx xxxxxx xxxxxx:
|
&xxxx; |
&xxxx; | &xxxx; | &xxxx; |
&xxxx;
Xxxxxxx:
|
&xxxx; | &xxxx; |
&xxxx; | &xxxx; | &xxxx; |
*) Xx xxxxxxx 1x xx xxxxx xxxxxxxx látka xxxxxxxx x přípravku uvedeném xx xxxxxxx 1x.
Xxxxxxxxxx xxxxxxx xxxxxxxxxxx souvislou xxxxx.
Xxxxxx č. ........... xxxxxx xxxxxx
Xxxxxx xxxxxxxxx xxxxxxx v jednotlivých xxxxxxxxx
XXX - Xxxxxxxx xxxxxxxxx a Rada
ES - Xxxxxxxx společenství
HVLP - xxxxxxxx vyráběný xxxxxx xxxxxxxxx
XXX - Xxxxxxxxxxxxx Xxxxxxxxxxxxxx Names
OL - xxxxxx xxxxx
XX - xxxxxxxxxxxx xxxxx
XXX - poštovní xxxxxxxxx xxxxx
XXXX - Státní xxxxx xxx xxxxxxxx xxxxx
Xxxxxxxxx
Xxxxxx předpis x. 125/2006 Sb. nabyl xxxxxxxxx xxxx 11.4.2006.
Ke xxx xxxxxxxx xxxxxx předpis xxxxx xxxxx či xxxxxxxxx.
Xxxxxx xxxxxxx x. 125/2006 Xx. xxx zrušen xxxxxxx xxxxxxxxx č. 53/2014 Sb. s xxxxxxxxx od 15.4.2014.
Znění xxxxxxxxxxxx xxxxxxxx norem xxxxxx xxxxxxxx xxxxxxxx v xxxxxxxx xxxx xxxxxxxxxxxxx, xxxxx xx jich xxxxxx xxxxxxxxx xxxxx xxxxx xxxxxxxxx právního xxxxxxxx.
1) Nařízení Xxxxxxxxxx xxxxxxxxxx a Xxxx (XX) č. 273/2004 ze xxx 11. února 2004 o prekursorech xxxx.
Xxxxxxxx Xxxx (XX) č. 111/2005 ze xxx 22. xxxxxxxx 2004, xxxxxx xx xxxxxxx xxxxxxxx pro sledování xxxxxxx x prekursory xxxx xxxx Xxxxxxxxxxxxx x třetími xxxxx.
Xxxxxxxx Xxxxxx (ES) č. 1277/2005 xx dne 27. xxxxxxxx 2005, kterým xx xxxxxxx xxxxxxxxx xxxxxxxx k xxxxxxxx Xxxxxxxxxx xxxxxxxxxx x Xxxx (XX) č. 273/2004 o xxxxxxxxxxxx xxxx x x xxxxxxxx Xxxx (ES) x. 111/2005, xxxxxx xx xxxxxxx xxxxxxxx xxx xxxxxxxxx xxxxxxx x prekursory drog xxxx Xxxxxxxxxxxxx a xxxxxxx xxxxxx.
2) Xxxxxxxx Xxxxxxxxxx xxxxxxxxxx x Xxxx (XX) č. 273/2004 ze xxx 11. xxxxx 2004 x xxxxxxxxxxxx xxxx.
3) Xxxxxxxx Rady (XX) č. 111/2005 xx xxx 22. prosince 2004, kterým xx xxxxxxx pravidla xxx xxxxxxxxx obchodu s xxxxxxxxxx drog mezi Xxxxxxxxxxxxx a třetími xxxxx.