ß, ___________________________________________________________________________________ _____________________________________________________________________________________, (íàéìåíóâàííÿ ïîñàäè, ïð³çâèùå, âëàñíå ³ì'ÿ, ïî áàòüêîâ³ (çà íàÿâíîñò³) îñîáè, ÿêà ñêëàëà ïðîòîêîë) ñêëàâ(ëà) öåé ïðîòîêîë ïðî òå, ùî îïåðàòîð ðèíêó _____________________________________________________________________________________ (íàéìåíóâàííÿ þðèäè÷íî¿ îñîáè / ïð³çâèùå, âëàñíå ³ì'ÿ, ïî áàòüêîâ³ (çà íàÿâíîñò³) ô³çè÷íî¿ îñîáè - ï³äïðèºìöÿ) Â÷èíèâ(ëà) ïðàâîïîðóøåííÿ ____________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ (ïîñèëàííÿ íà ïîëîæåííÿ íîðìàòèâíî-ïðàâîâîãî àêòà (³ç çàçíà÷åííÿì â³äïîâ³äíèõ àáçàö³â, ïóíêò³â, ÷àñòèí, ñòàòåé), ÿêå áóëî ïîðóøåíî îïåðàòîðîì ðèíêó, ùîäî ÿêîãî ñêëàäåíî ïðîòîêîë) Ñóòü â÷èíåíîãî ïðàâîïîðóøåííÿ: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ̳ñöå â÷èíåííÿ ïðàâîïîðóøåííÿ: _______________________________________________________ ×àñ â÷èíåííÿ ïðàâîïîðóøåííÿ: _________________________________________________________ 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 òâàðèí òà áëàãîïîëó÷÷ÿ òâàðèí", çàêîíîäàâñòâà ïðî õàð÷îâ³ ïðîäóêòè, êîðìè, ïîá³÷í³ ïðîäóêòè òâàðèííîãî ïîõîäæåííÿ, çäîðîâ'ÿ òâàðèí òà áëàãîïîëó÷÷ÿ òâàðèí îïåðàòîðîì ðèíêó, ùîäî ÿêîãî ñêëàäåíî ïðîòîêîë _____________________________________________________________________________________ (çàçíà÷àþòüñÿ äàòà ñêëàäàííÿ àêòà òà éîãî íîìåð, _____________________________________________________________________________________ ïîñàäà, ïð³çâèùå, âëàñíå ³ì'ÿ, ïî áàòüêîâ³ (çà íàÿâíîñò³) ÿêà éîãî ñêëàëà, ðåêâ³çèòè _____________________________________________________________________________________ ³íøèõ äîêàç³â, ÿêèìè ï³äòâåðäæóºòüñÿ â÷èíåííÿ ïîðóøåííÿ, òîùî) ³äîìîñò³ ïðî îïåðàòîðà ðèíêó, ùîäî ÿêîãî ñêëàäàºòüñÿ ïðîòîêîë: 1. Ïîâíå òà ñêîðî÷åíå (çà íàÿâíîñò³) íàéìåíóâàííÿ ñóá'ºêòà ãîñïîäàðþâàííÿ / ïð³çâèùå, âëàñíå ³ì'ÿ, ïî áàòüêîâ³ (çà íàÿâíîñò³) ô³çè÷íî¿ îñîáè - ï³äïðèºìöÿ ____________________________________ _____________________________________________________________________________________ 2. ²äåíòèô³êàö³éíèé êîä þðèäè÷íî¿ îñîáè â ªäèíîìó äåðæàâíîìó ðåºñòð³ ï³äïðèºìñòâ òà îðãàí³çàö³é Óêðà¿íè / ðåºñòðàö³éíèé íîìåð îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â àáî ñåð³ÿ (çà íàÿâíîñò³) òà íîìåð ïàñïîðòà (äëÿ ô³çè÷íî¿ îñîáè, ÿêà ÷åðåç ñâî¿ ðåë³ã³éí³ ïåðåêîíàííÿ â³äìîâëÿºòüñÿ â³ä ïðèéíÿòòÿ ðåºñòðàö³éíîãî íîìåðà îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â òà ïîâ³äîìèëà ïðî öå â³äïîâ³äíîìó êîíòðîëþþ÷îìó îðãàíó ³ ìຠâ³äïîâ³äíó â³äì³òêó â ïàñïîðò³) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 3. ̳ñöåçíàõîäæåííÿ þðèäè÷íî¿ îñîáè çàäåêëàðîâàíå / çàðåºñòðîâàíå ì³ñöå ïðîæèâàííÿ (ïåðåáóâàííÿ) ô³çè÷íî¿ îñîáè - ï³äïðèºìöÿ _______________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ (³íäåêñ, îáëàñòü, ì³ñòî (ñåëèùå àáî ñåëî), âóëèöÿ, áóäèíîê) 4. Àäðåñà â³äïîâ³äíî¿ ïîòóæíîñò³ _____________________________________________________________________________________ _____________________________________________________________________________________ 5. Êîíòàêòí³ äàí³ _____________________________________________________________________________________ (íîìåð òåëåôîíó òà/àáî àäðåñà åëåêòðîííî¿ ïîøòè) 6. ³äîìîñò³ ïðî ïðåäñòàâíèêà ñóá'ºêòà ãîñïîäàðþâàííÿ (íàéìåíóâàííÿ ïîñàäè, ïð³çâèùå, âëàñíå ³ì'ÿ, ïî áàòüêîâ³ (çà íàÿâíîñò³), ðåºñòðàö³éíèé íîìåð îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â, ñåð³ÿ (çà íàÿâíîñò³) òà íîìåð ïàñïîðòà (äëÿ ô³çè÷íî¿ îñîáè, ÿêà ÷åðåç ñâî¿ ðåë³ã³éí³ ïåðåêîíàííÿ â³äìîâëÿºòüñÿ â³ä ïðèéíÿòòÿ ðåºñòðàö³éíîãî íîìåðà îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â òà ïîâ³äîìèëà ïðî öå â³äïîâ³äíîìó êîíòðîëþþ÷îìó îðãàíó ³ ìຠâ³äïîâ³äíó â³äì³òêó â ïàñïîðò³), à òàêîæ ðåêâ³çèòè äîêóìåíòà, ùî ï³äòâåðäæóº ¿¿ ïîâíîâàæåííÿ) _____________________________________________________________________________________ _____________________________________________________________________________________ Ñâ³äêè ïðàâîïîðóøåííÿ (çà íàÿâíîñò³): 1. Ïð³çâèùå, âëàñíå ³ì'ÿ, ïî áàòüêîâ³ (çà íàÿâíîñò³) _________________________________________ _____________________________________________________________________________________ Çàäåêëàðîâàíå / çàðåºñòðîâàíå ì³ñöå ïðîæèâàííÿ (ïåðåáóâàííÿ) _____________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ (³íäåêñ, îáëàñòü, ì³ñòî (ñåëèùå àáî ñåëî), âóëèöÿ, áóäèíîê) Êîíòàêòí³ äàíí³ _______________________________________________________________________ (íîìåð òåëåôîíó òà/àáî àäðåñà åëåêòðîííî¿ ïîøòè) Ïîÿñíåííÿ ___________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ϳäïèñ __________________ 2. Ïð³çâèùå, âëàñíå ³ì'ÿ, ïî áàòüêîâ³ (çà íàÿâíîñò³) _________________________________________ _____________________________________________________________________________________ Çàäåêëàðîâàíå / çàðåºñòðîâàíå ì³ñöå ïðîæèâàííÿ (ïåðåáóâàííÿ) _____________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ (³íäåêñ, îáëàñòü, ì³ñòî (ñåëèùå àáî ñåëî), âóëèöÿ, áóäèíîê) Êîíòàêòí³ äàí³ ________________________________________________________________________ (íîìåð òåëåôîíó òà/àáî àäðåñà åëåêòðîííî¿ ïîøòè) Ïîÿñíåííÿ ___________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ϳäïèñ __________________ Ïîòåðï³ë³ (çà íàÿâíîñò³): 1. Ïîâíå òà ñêîðî÷åíå (çà íàÿâíîñò³) íàéìåíóâàííÿ ñóá'ºêòà ãîñïîäàðþâàííÿ / ïð³çâèùå, âëàñíå ³ì'ÿ, ïî áàòüêîâ³ (çà íàÿâíîñò³) ô³çè÷íî¿ îñîáè ________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ²äåíòèô³êàö³éíèé êîä þðèäè÷íî¿ îñîáè â ªäèíîìó äåðæàâíîìó ðåºñòð³ ï³äïðèºìñòâ òà îðãàí³çàö³é Óêðà¿íè / ðåºñòðàö³éíèé íîìåð îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â àáî ñåð³ÿ (çà íàÿâíîñò³) òà íîìåð ïàñïîðòà (äëÿ ô³çè÷íî¿ îñîáè, ÿêà ÷åðåç ñâî¿ ðåë³ã³éí³ ïåðåêîíàííÿ â³äìîâëÿºòüñÿ â³ä ïðèéíÿòòÿ ðåºñòðàö³éíîãî íîìåðà îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â òà ïîâ³äîìèëà ïðî öå â³äïîâ³äíîìó êîíòðîëþþ÷îìó îðãàíó ³ ìຠâ³äïîâ³äíó â³äì³òêó â ïàñïîðò³) ________________________________ Çàäåêëàðîâàíå / çàðåºñòðîâàíå ì³ñöå ïðîæèâàííÿ (ïåðåáóâàííÿ) _____________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ (³íäåêñ, îáëàñòü, ì³ñòî (ñåëèùå àáî ñåëî), âóëèöÿ, áóäèíîê) Êîíòàêòí³ äàí³ ________________________________________________________________________ (íîìåð òåëåôîíó òà/àáî àäðåñà åëåêòðîííî¿ ïîøòè) Ïîÿñíåííÿ ___________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ϳäïèñ __________________ 2. Ïîâíå òà ñêîðî÷åíå (çà íàÿâíîñò³) íàéìåíóâàííÿ ñóá'ºêòà ãîñïîäàðþâàííÿ / ïð³çâèùå, âëàñíå ³ì'ÿ, ïî áàòüêîâ³ (çà íàÿâíîñò³) ô³çè÷íî¿ îñîáè ________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ²äåíòèô³êàö³éíèé êîä þðèäè÷íî¿ îñîáè â ªäèíîìó äåðæàâíîìó ðåºñòð³ ï³äïðèºìñòâ òà îðãàí³çàö³é Óêðà¿íè / ðåºñòðàö³éíèé íîìåð îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â àáî ñåð³ÿ (çà íàÿâíîñò³) òà íîìåð ïàñïîðòà (äëÿ ô³çè÷íî¿ îñîáè, ÿêà ÷åðåç ñâî¿ ðåë³ã³éí³ ïåðåêîíàííÿ â³äìîâëÿºòüñÿ â³ä ïðèéíÿòòÿ ðåºñòðàö³éíîãî íîìåðà îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â òà ïîâ³äîìèëà ïðî öå â³äïîâ³äíîìó êîíòðîëþþ÷îìó îðãàíó ³ ìຠâ³äïîâ³äíó â³äì³òêó â ïàñïîðò³) Çàäåêëàðîâàíå / çàðåºñòðîâàíå ì³ñöå ïðîæèâàííÿ (ïåðåáóâàííÿ) _____________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ (³íäåêñ, îáëàñòü, ì³ñòî (ñåëèùå àáî ñåëî), âóëèöÿ, áóäèíîê) Êîíòàêòí³ äàí³ ________________________________________________________________________ (íîìåð òåëåôîíó òà/àáî àäðåñà åëåêòðîííî¿ ïîøòè) Ïîÿñíåííÿ ___________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ϳäïèñ __________________ ²íø³ â³äîìîñò³, ùî ñïðèÿþòü âñåá³÷íîìó òà îá'ºêòèâíîìó ðîçãëÿäó ³ âèð³øåííþ ñïðàâè (çà íàÿâíîñò³) ___________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Ïîÿñíåííÿ îïåðàòîðà ðèíêó, ùîäî ÿêîãî ñêëàäåíî ïðîòîêîë, àáî éîãî ïðåäñòàâíèêà ÷è çàïèñ îñîáè, ÿêà ñêëàëà ïðîòîêîë ïðî â³äìîâó â³ä íàäàííÿ ïîÿñíåíü ³ç çàçíà÷åííÿì ÷àñó, äàòè òà ñâ³äê³â â³äìîâè (çà íàÿâíîñò³) _________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ϳäïèñ __________________ Çàïèñ ïðî òå, ùî äî ïðîòîêîëó äîäàþòüñÿ ïîÿñíåííÿ íà îêðåìîìó àðêóø³, çàñâ³ä÷åí³ ï³äïèñàìè îïåðàòîðà ðèíêó, ùîäî ÿêîãî ñêëàäåíî ïðîòîêîë, àáî éîãî ïðåäñòàâíèêà, ñâ³äê³â òà/àáî ïîòåðï³ëèõ (çà íàÿâíîñò³) _____________________________________________________________________________________ _____________________________________________________________________________________ ϳäïèñ îñîáè, ÿêà ñêëàëà ïðîòîêîë ______________________________________________________ dz çì³ñòîì ïðîòîêîëó îçíàéîìëåíèé(íà): |