Çàÿâëåíèå î âûäà÷å ðàçðåøåíèÿ íà

 ïðèìåíåíèå ôðàíêèðîâàëüíîé ìàøèíû

 

 1. Âëàäåëåö ôðàíêèðîâàëüíîé

 ìàøèíû:      __________________________________________________________________

______________________________________________________________________________

(ïîëíîå íàèìåíîâàíèå, îðãàíèçàöèîííî-ïðàâîâàÿ ôîðìà þðèäè÷åñêîãî ëèöà â ñîîòâåòñòâèè

ñ ó÷ðåäèòåëüíûìè äîêóìåíòàìè (ôàìèëèÿ, èìÿ, îò÷åñòâî (ïðè íàëè÷èè) èíäèâèäóàëüíîãî ïðåäïðèíèìàòåëÿ)

 

 2. Àäðåñ ìåñòîíàõîæäåíèÿ:     ____________________________________________________

______________________________________________________________________________

                                                                              (ìåñòî íàõîæäåíèÿ (ìåñòî æèòåëüñòâà)

                                                                               þðèäè÷åñêîãî ëèöà (èíäèâèäóàëüíîãî

                                                                                             ïðåäïðèíèìàòåëÿ)

 3. Ïî÷òîâûé àäðåñ:  ____________________________________________________________

______________________________________________________________________________

                                                                              (ïî÷òîâûé àäðåñ þðèäè÷åñêîãî ëèöà

                                                                              (èíäèâèäóàëüíîãî ïðåäïðèíèìàòåëÿ)

 4. ÈÍÍ (ÊÏÏ) _________________________________________________________________

                                                                             (ÈÍÍ þðèäè÷åñêîãî ëèöà (äëÿ ôèëèàëà

                                                                               þðèäè÷åñêîãî ëèöà äîïîëíèòåëüíî

                                                                                óêàçûâàåòñÿ ÊÏÏ), èíäèâèäóàëüíîãî

                                                                                           ïðåäïðèíèìàòåëÿ)

 5. ÎÃÐÍ/ÎÃÐÍÈÏ _____________________________________________________________

                                                            (ÎÃÐÍ þðèäè÷åñêîãî ëèöà, äëÿ

                                                                             èíäèâèäóàëüíîãî ïðåäïðèíèìàòåëÿ

                                                                                        óêàçûâàåòñÿ ÎÃÐÍÈÏ)

 6. Êîíòàêòíûé òåëåôîí  ___________________, Ôàêñ çàÿâèòåëÿ_______________________

 7. Íàèìåíîâàíèå ìîäåëè

 (ñåðèè) ôðàíêèðîâàëüíîé

 ìàøèíû: __________ ___________________________________________________________

 8. Ìåñòî óñòàíîâêè

 ôðàíêèðîâàëüíîé ìàøèíû: ______________________________________________________

______________________________________________________________________________

 9. Âîçìîæíûå äàòà è âðåìÿ

 ïðîâåäåíèÿ îáñëåäîâàíèÿ

 ôðàíêèðîâàëüíîé ìàøèíû: ______________________________________________________

 10. Ïîäïèñü âëàäåëüöà

 ôðàíêèðîâàëüíîé ìàøèíû:_____________ _________________________________________

                                                                                (ñ óêàçàíèåì äîëæíîñòè, ôàìèëèè, èìåíè,

                                                                                 îò÷åñòâà (ïðè íàëè÷èè) ïîëíîñòüþ, ñ

                                                                                  ïðîñòàâëåíèåì ïå÷àòè þðèäè÷åñêîãî ëèöà

                                                                                  (èíäèâèäóàëüíîãî ïðåäïðèíèìàòåëÿ)