"___" ____________ 20__ ðîêó |
________________________
(ì³ñöå ñêëàäàííÿ) |
³äîìîñò³ ïðî îñîáó, ÿêà ñêëàëà ïðîòîêîë
Ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ ______________________________________________________________
Ïîñàäà _______________________________________________________________________________
Íîìåð çàñîáó çâ'ÿçêó ___________________________________________________________________
³äîìîñò³ ïðî îïåðàòîðà ðèíêó, ùîäî ÿêîãî ñêëàäàºòüñÿ ïðîòîêîë
Íàéìåíóâàííÿ (äëÿ þðèäè÷íî¿ îñîáè) àáî ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ (äëÿ ô³çè÷íî¿ îñîáè - ï³äïðèºìöÿ) __________________________________________________________________________
_____________________________________________________________________________________
²äåíòèô³êàö³éíèé êîä (äëÿ þðèäè÷íî¿ îñîáè), àáî ðåºñòðàö³éíèé íîìåð îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â (äëÿ ô³çè÷íî¿ îñîáè - ï³äïðèºìöÿ), àáî ñåð³ÿ (çà íàÿâíîñò³) òà íîìåð ïàñïîðòà (äëÿ ô³çè÷íèõ îñ³á - ï³äïðèºìö³â, ÿê³ ÷åðåç ñâî¿ ðåë³ã³éí³ ïåðåêîíàííÿ â³äìîâëÿþòüñÿ â³ä ïðèéíÿòòÿ ðåºñòðàö³éíîãî íîìåðà îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â òà ïîâ³äîìèëè ïðî öå â³äïîâ³äíèé êîíòðîëþþ÷èé îðãàí ³ ìàþòü â³äì³òêó ó ïàñïîðò³) _______________________________________________________________
______________________________________________________________________________________
̳ñöåçíàõîäæåííÿ (äëÿ þðèäè÷íî¿ îñîáè) àáî ì³ñöå ïðîæèâàííÿ (äëÿ ô³çè÷íî¿ îñîáè - ï³äïðèºìöÿ) ______________________________________________________________________________________
______________________________________________________________________________________
Àäðåñà â³äïîâ³äíî¿ ïîòóæíîñò³ ____________________________________________________________
______________________________________________________________________________________
Óïîâíîâàæåíà îñîáà (ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³, ðåºñòðàö³éíèé íîìåð îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â àáî ñåð³ÿ (çà íàÿâíîñò³) òà íîìåð ïàñïîðòà (äëÿ îñ³á, ÿê³ ÷åðåç ñâî¿ ðåë³ã³éí³ ïåðåêîíàííÿ â³äìîâëÿþòüñÿ â³ä ïðèéíÿòòÿ ðåºñòðàö³éíîãî íîìåðà îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â òà ïîâ³äîìèëè ïðî öå â³äïîâ³äíèé êîíòðîëþþ÷èé îðãàí ³ ìàþòü â³äì³òêó ó ïàñïîðò³) òà ðåêâ³çèòè äîêóìåíòà, ùî ï³äòâåðäæóº ¿¿ ïîâíîâàæåííÿ) _______________________________________________
______________________________________________________________________________________
Íîìåð çàñîáó çâ'ÿçêó ____________________________________________________________________
²íôîðìàö³ÿ ïðî ïîðóøåííÿ
̳ñöå â÷èíåííÿ ïîðóøåííÿ _____________________________________________________________
Äàòà òà ÷àñ â÷èíåííÿ ïîðóøåííÿ _________________________________________________________
Ñóòü ïîðóøåííÿ _______________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Ïîñèëàííÿ íà ïîëîæåííÿ íîðìàòèâíî-ïðàâîâîãî àêòà (³ç çàçíà÷åííÿì â³äïîâ³äíî¿ ñòàòò³, ïóíêòó, ¿¿ (éîãî) ÷àñòèíè ÷è àáçàöó), ÿêå áóëî ïîðóøåíî îñîáîþ, ùîäî ÿêî¿ ñêëàäåíî ïðîòîêîë
______________________________________________________________________________________
______________________________________________________________________________________
Ïîñèëàííÿ íà àêò äåðæàâíîãî êîíòðîëþ òà ³íø³ äîêàçè, ÿêèìè ï³äòâåðäæóºòüñÿ â÷èíåííÿ ïîðóøåííÿ Çàêîíó Óêðà¿íè "Ïðî äåðæàâíèé êîíòðîëü çà äîòðèìàííÿì çàêîíîäàâñòâà ïðî õàð÷îâ³ ïðîäóêòè, êîðìè, ïîá³÷í³ ïðîäóêòè òâàðèííîãî ïîõîäæåííÿ, çäîðîâ'ÿ òà áëàãîïîëó÷÷ÿ òâàðèí", çàêîíîäàâñòâà ïðî õàð÷îâ³ ïðîäóêòè òà êîðìè îñîáîþ, ùîäî ÿêî¿ ñêëàäåíî ïðîòîêîë ______________________________________________________________________________________
(çàçíà÷àþòüñÿ äàòà ñêëàäàííÿ àêòà òà éîãî íîìåð,
______________________________________________________________________________________
ïîñàäà, ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ îñîáè, ÿêà éîãî ñêëàëà, ðåêâ³çèòè
______________________________________________________________________________________
³íøèõ äîêàç³â, ÿêèìè ï³äòâåðäæóºòüñÿ â÷èíåííÿ ïîðóøåííÿ, òîùî)
²íôîðìàö³ÿ ïðî ñâ³äê³â ïîðóøåííÿ (ÿêùî âîíè º)
1. Ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ _____________________________________________________________
̳ñöå ïðîæèâàííÿ _____________________________________________________________________
______________________________________________________________________________________
Íîìåð çàñîáó çâ'ÿçêó ____________________________________________________________________
Ïîÿñíåííÿ ____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
ϳäïèñ __________________________
2. Ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ _____________________________________________________________
̳ñöå ïðîæèâàííÿ _____________________________________________________________________
______________________________________________________________________________________
Íîìåð çàñîáó çâ'ÿçêó ___________________________________________________________________
Ïîÿñíåííÿ ___________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
ϳäïèñ __________________________
²íôîðìàö³ÿ ïðî ïîòåðï³ëèõ (ÿêùî âîíè º):
1. Íàéìåíóâàííÿ (äëÿ þðèäè÷íî¿ îñîáè) àáî ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ (äëÿ ô³çè÷íî¿ îñîáè) _____________________________________________________________________________________
_____________________________________________________________________________________
²äåíòèô³êàö³éíèé êîä (äëÿ þðèäè÷íî¿ îñîáè), àáî ðåºñòðàö³éíèé íîìåð îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â (äëÿ ô³çè÷íî¿ îñîáè), àáî ñåð³ÿ (çà íàÿâíîñò³) òà íîìåð ïàñïîðòà (äëÿ ô³çè÷íèõ îñ³á, ÿê³ ÷åðåç ñâî¿ ðåë³ã³éí³ ïåðåêîíàííÿ â³äìîâëÿþòüñÿ â³ä ïðèéíÿòòÿ ðåºñòðàö³éíîãî íîìåðà îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â òà ïîâ³äîìèëè ïðî öå â³äïîâ³äíèé êîíòðîëþþ÷èé îðãàí ³ ìàþòü â³äì³òêó ó ïàñïîðò³) ______________________________________________________________________________
̳ñöåçíàõîäæåííÿ (äëÿ þðèäè÷íî¿ îñîáè) àáî ì³ñöå ïðîæèâàííÿ (äëÿ ô³çè÷íî¿ îñîáè) ______________________________________________________________________________________
______________________________________________________________________________________
Íîìåð çàñîáó çâ'ÿçêó ____________________________________________________________________
Ïîÿñíåííÿ ____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
ϳäïèñ __________________________
2. Íàéìåíóâàííÿ (äëÿ þðèäè÷íî¿ îñîáè) àáî ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ (äëÿ ô³çè÷íî¿ îñîáè) _____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
²äåíòèô³êàö³éíèé êîä (äëÿ þðèäè÷íî¿ îñîáè), àáî ðåºñòðàö³éíèé íîìåð îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â (äëÿ ô³çè÷íî¿ îñîáè), àáî ñåð³ÿ (çà íàÿâíîñò³) òà íîìåð ïàñïîðòà (äëÿ ô³çè÷íèõ îñ³á, ÿê³ ÷åðåç ñâî¿ ðåë³ã³éí³ ïåðåêîíàííÿ â³äìîâëÿþòüñÿ â³ä ïðèéíÿòòÿ ðåºñòðàö³éíîãî íîìåðà îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â òà ïîâ³äîìèëè ïðî öå â³äïîâ³äíèé êîíòðîëþþ÷èé îðãàí ³ ìàþòü â³äì³òêó ó ïàñïîðò³) ______________________________________________________________________________
̳ñöåçíàõîäæåííÿ (äëÿ þðèäè÷íî¿ îñîáè) àáî ì³ñöå ïðîæèâàííÿ (äëÿ ô³çè÷íî¿ îñîáè) _____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Íîìåð çàñîáó çâ'ÿçêó ___________________________________________________________________
Ïîÿñíåííÿ ___________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
ϳäïèñ __________________________
²íø³ â³äîìîñò³, ùî ñïðèÿþòü âñåá³÷íîìó òà îá'ºêòèâíîìó ðîçãëÿäó ³ âèð³øåííþ ñïðàâè (çà íàÿâíîñò³) ____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Ïîÿñíåííÿ îñîáè, ùîäî ÿêî¿ ñêëàäåíî ïðîòîêîë, àáî ¿¿ ïðåäñòàâíèêà ÷è çàïèñ ïðî â³äìîâó â³ä íàäàííÿ ïîÿñíåíü______________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
ϳäïèñ_______________________________
Çàïèñ ïðî òå, ùî äî ïðîòîêîëó íàäàþòüñÿ ïîÿñíåííÿ íà îêðåìîìó àðêóø³, çàñâ³ä÷åí³ ï³äïèñàìè îñîáè, ùîäî ÿêî¿ ñêëàäåíî ïðîòîêîë, àáî ¿¿ ïðåäñòàâíèêà, ñâ³äê³â òà/àáî ïîòåðï³ëèõ ______________________________________________________________________________________
______________________________________________________________________________________
ϳäïèñ îñîáè, ÿêà ñêëàëà ïðîòîêîë ____________________________________
dz çì³ñòîì ïðîòîêîëó îçíàéîìëåíèé/îçíàéîìëåíà "___" ____________ 20__ ðîêó.
Îïåðàòîð ðèíêó àáî óïîâíîâàæåíà íèì îñîáà ______________________________________________
(ï³äïèñ, ³í³ö³àëè, ïð³çâèùå)
ϳäïèñ îñîáè, ÿêà ñêëàëà ïðîòîêîë, ùî ï³äòâåðäæóº â³äìîâó îïåðàòîðà ðèíêó àáî óïîâíîâàæåíî¿ íèì îñîáè â³ä ï³äïèñàííÿ ïðîòîêîëó __________________________________________________________
Äðóãèé ïðèì³ðíèê ïðîòîêîëó ïðî ïîðóøåííÿ îòðèìàâ
"___" ____________ 20__ ðîêó ____________ _______________________________________________
(äàòà) (ï³äïèñ) (³ì'ÿ, ïî áàòüêîâ³, ïð³çâèùå îñîáè, ùî îòðèìàëà ïðîòîêîë)
_____________________________________________________________________________________
(ó ðàç³ â³äìîâè îïåðàòîðà ðèíêó àáî óïîâíîâàæåíî¿ íèì îñîáè â³ä îòðèìàííÿ ïðèì³ðíèêà ïðîòîêîëó ïðî öå
ðîáèòüñÿ çàïèñ)
Ïðèì³òêà. Ó ðàç³ â³äìîâè îïåðàòîðà ðèíêó àáî óïîâíîâàæåíî¿ íèì îñîáè â³ä îòðèìàííÿ ïðèì³ðíèêà ïðîòîêîëó ïðîòîêîë íàäñèëàºòüñÿ íå ï³çí³øå íàñòóïíîãî ðîáî÷îãî äíÿ ï³ñëÿ éîãî ñêëàäàííÿ îïåðàòîðó ðèíêó ðåêîìåíäîâàíèì ïîøòîâèì â³äïðàâëåííÿì ³ç ïîâ³äîìëåííÿì ïðî âðó÷åííÿ òà çàçíà÷åííÿì íà äðóãîìó ïðèì³ðíèêó â³äîìîñòåé ïðî çä³éñíåííÿ ïîøòîâîãî â³äïðàâëåííÿ. |