"___" ____________ 20__ ðîêó

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(ì³ñöå ñêëàäàííÿ ïðîòîêîëó)

³äîìîñò³ ïðî îñîáó, ÿêà ñêëàëà ïðîòîêîë:

Ïð³çâèùå, ³ì'ÿ òà 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): __________________________________________________________________________
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²äåíòèô³êàö³éíèé êîä (äëÿ þðèäè÷íî¿ îñîáè) àáî ðåºñòðàö³éíèé íîìåð îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â (äëÿ ô³çè÷íî¿ îñîáè - ï³äïðèºìöÿ) ÷è ñåð³ÿ òà íîìåð ïàñïîðòà (äëÿ ô³çè÷íèõ îñ³á - ï³äïðèºìö³â, ÿê³ ÷åðåç ñâî¿ ðåë³ã³éí³ ïåðåêîíàííÿ â³äìîâèëèñü â³ä ïðèéíÿòòÿ òàêîãî íîìåðà): ______
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̳ñöåçíàõîäæåííÿ (äëÿ þðèäè÷íî¿ îñîáè) àáî ì³ñöå ïðîæèâàííÿ (äëÿ ô³çè÷íî¿ îñîáè - ï³äïðèºìöÿ): _____________________________________________________________________________________
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Óïîâíîâàæåíà îñîáà (ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³, ðåºñòðàö³éíèé íîìåð îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â ÷è ñåð³ÿ òà íîìåð ïàñïîðòà (äëÿ îñ³á, ÿê³ ÷åðåç ñâî¿ ðåë³ã³éí³ ïåðåêîíàííÿ â³äìîâèëèñü â³ä ïðèéíÿòòÿ òàêîãî íîìåðà) òà ðåêâ³çèòè äîêóìåíòà, ùî ï³äòâåðäæóº ¿¿ ïîâíîâàæåííÿ): _____________
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Íîìåð çàñîáó çâ'ÿçêó: ___________________________________________________________________

²íôîðìàö³ÿ ïðî ïðàâîïîðóøåííÿ:

̳ñöå â÷èíåííÿ ïðàâîïîðóøåííÿ: ________________________________________________________
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Äàòà òà ÷àñ â÷èíåííÿ ïðàâîïîðóøåííÿ: ___________________________________________________

Ñóòü ïðàâîïîðóøåííÿ: _________________________________________________________________
                                                                                      (âèêëàäàºòüñÿ ³ç çàçíà÷åííÿì àáçàö³â, ïóíêò³â, ÷àñòèí, ñòàòåé
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                                                                          íîðìàòèâíî-ïðàâîâèõ àêò³â, ÿê³ áóëî ïîðóøåíî)
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Íîðìàòèâíî-ïðàâîâèé àêò, ÿêèé ïåðåäáà÷ຠâ³äïîâ³äàëüí³ñòü çà â÷èíåíå ïðàâîïîðóøåííÿ: Çàêîí Óêðà¿íè "Ïðî îñíîâí³ ïðèíöèïè òà âèìîãè äî áåçïå÷íîñò³ òà ÿêîñò³ õàð÷îâèõ ïðîäóêò³â" (ñòàòòÿ 64).

²íôîðìàö³ÿ ïðî ñâ³äê³â ïðàâîïîðóøåííÿ (ÿêùî âîíè º):

1. Ïð³çâèùå, ³ì'ÿ òà ïî áàòüêîâ³: __________________________________________________________

̳ñöå ïðîæèâàííÿ: ____________________________________________________________________
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Íîìåð çàñîáó çâ'ÿçêó: ___________________________________________________________________

ϳäïèñ: _____________________________________________

2. Ïð³çâèùå, ³ì'ÿ òà ïî áàòüêîâ³: __________________________________________________________

̳ñöå ïðîæèâàííÿ: ____________________________________________________________________
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Íîìåð çàñîáó çâ'ÿçêó: ___________________________________________________________________

ϳäïèñ: _____________________________________________

3. Ïð³çâèùå, ³ì'ÿ òà ïî áàòüêîâ³: __________________________________________________________

̳ñöå ïðîæèâàííÿ: ____________________________________________________________________
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Íîìåð çàñîáó çâ'ÿçêó: ___________________________________________________________________

ϳäïèñ: ____________________________________________

²íôîðìàö³ÿ ïðî ïîòåðï³ëèõ (ÿêùî âîíè º):

1. Íàéìåíóâàííÿ (äëÿ þðèäè÷íî¿ îñîáè) àáî ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ (äëÿ ô³çè÷íî¿ îñîáè): _____________________________________________________________________________________
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²äåíòèô³êàö³éíèé êîä (äëÿ þðèäè÷íî¿ îñîáè) àáî ðåºñòðàö³éíèé íîìåð îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â (äëÿ ô³çè÷íî¿ îñîáè) ÷è ñåð³ÿ òà íîìåð ïàñïîðòà (äëÿ ô³çè÷íèõ îñ³á, ÿê³ ÷åðåç ñâî¿ ðåë³ã³éí³ ïåðåêîíàííÿ â³äìîâèëèñü â³ä ïðèéíÿòòÿ òàêîãî íîìåðà): _____________________________________

̳ñöåçíàõîäæåííÿ (äëÿ þðèäè÷íî¿ îñîáè) àáî ì³ñöå ïðîæèâàííÿ (äëÿ ô³çè÷íî¿ îñîáè): _____________________________________________________________________________________
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Íîìåð çàñîáó çâ'ÿçêó: ___________________________________________________________________

ϳäïèñ: _____________________________________________

2. Íàéìåíóâàííÿ (äëÿ þðèäè÷íî¿ îñîáè) àáî ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ (äëÿ ô³çè÷íî¿ îñîáè): _____________________________________________________________________________________
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²äåíòèô³êàö³éíèé êîä (äëÿ þðèäè÷íî¿ îñîáè) àáî ðåºñòðàö³éíèé íîìåð îáë³êîâî¿ êàðòêè ïëàòíèêà ïîäàòê³â (äëÿ ô³çè÷íî¿ îñîáè) ÷è ñåð³ÿ òà íîìåð ïàñïîðòà (äëÿ ô³çè÷íèõ îñ³á, ÿê³ ÷åðåç ñâî¿ ðåë³ã³éí³ ïåðåêîíàííÿ â³äìîâèëèñü â³ä ïðèéíÿòòÿ òàêîãî íîìåðà): _____________________________________

̳ñöåçíàõîäæåííÿ (äëÿ þðèäè÷íî¿ îñîáè) àáî ì³ñöå ïðîæèâàííÿ (äëÿ ô³çè÷íî¿ îñîáè): _____________________________________________________________________________________
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Íîìåð çàñîáó çâ'ÿçêó: ___________________________________________________________________

ϳäïèñ: _____________________________________________

3. 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) ÷è ñåð³ÿ òà íîìåð ïàñïîðòà (äëÿ ô³çè÷íèõ îñ³á, ÿê³ ÷åðåç ñâî¿ ðåë³ã³éí³ ïåðåêîíàííÿ â³äìîâèëèñü â³ä ïðèéíÿòòÿ òàêîãî íîìåðà): _____________________________________

̳ñöåçíàõîäæåííÿ (äëÿ þðèäè÷íî¿ îñîáè) àáî ì³ñöå ïðîæèâàííÿ (äëÿ ô³çè÷íî¿ îñîáè): _____________________________________________________________________________________
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Íîìåð çàñîáó çâ'ÿçêó: ___________________________________________________________________

ϳäïèñ: _____________________________________________

²íôîðìàö³ÿ ïðî øêîäó, çàâäàíó ïðàâîïîðóøåííÿì: ______________________________________
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Ïîÿñíåííÿ îñîáè, ÿêà ïðèòÿãàºòüñÿ äî â³äïîâ³äàëüíîñò³, òà/àáî çàïèñ ïðî òå, ùî ¿¿ ïîÿñíåííÿ ³ çàóâàæåííÿ ùîäî çì³ñòó ïðîòîêîëó äîäàþòüñÿ äî íüîãî: __________________________________
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²íø³ â³äîìîñò³, íåîáõ³äí³ äëÿ âèð³øåííÿ ñïðàâè: _________________________________________
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ϳäïèñ îñîáè, ÿêà ñêëàëà ïðîòîêîë: ____________________________________________________

Ì. Ï.

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: __________________________________________________________
                                                                                                                                                                  Ì. Ï.

Ìîòèâè â³äìîâè â³ä ï³äïèñàííÿ ïðîòîêîëó: ________________________________________________
                                                                                                                (çàïîâíþºòüñÿ îñîáîþ, ÿêà â³äìîâèëàñÿ â³ä ï³äïèñàííÿ)

Äðóãèé ïðèì³ðíèê ïðîòîêîëó ïðî ïðàâîïîðóøåííÿ îòðèìàâ
"___" ____________ 20__ ðîêó ____________ ______________________________________________
                       (äàòà)                                             (ï³äïèñ)               (³ì'ÿ, ïî áàòüêîâ³ òà ïð³çâèùå îñîáè, ùî îòðèìàëà ïðîòîêîë)

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                  (ó ðàç³ â³äìîâè îïåðàòîðà ðèíêó àáî óïîâíîâàæåíî¿ íèì îñîáè â³ä îòðèìàííÿ ïðèì³ðíèêà ïðîòîêîëó
                                                                                          ðîáèòüñÿ çàïèñ ïðî öå)

Ïðèì³òêà. Ó ðàç³ â³äìîâè îïåðàòîðà ðèíêó àáî óïîâíîâàæåíî¿ íèì îñîáè â³ä îòðèìàííÿ ïðèì³ðíèêà ïðîòîêîëó îñòàíí³é ïîâèíåí áóòè íàä³ñëàíèé îïåðàòîðó ðèíêó ðåêîìåíäîâàíèì ïîøòîâèì â³äïðàâëåííÿì ç ïîâ³äîìëåííÿì ïðî âðó÷åííÿ.