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Obrazac C-O-01: ZAHTJEV ZA ISPITIVANJE VOZILA

Potvrda broj: …………………..

SVRHA ISPITIVANJA: ..................................................................................................................

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PRILOŽENI DOKUMENTI: .............................................................................................................

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………………………………………………………………………………………………………………………..

PODACI O VOZILU

Marka i tip: ..........................................................VIN oznaka: .......................................................

Registarska oznaka: ............................................Vrsta vozila: .......................................................

VLASNIK VOZILA DOSTAVITI


Naziv / matični broj: .
……………………….......................................................................................................................
Adresa:
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PODNOSITELJ ZAHTJEVA

Ime prezime/Naziv tvrtke ................................................................................................................

JIB/IB: ................................................................. PDV/PIB: .....................................................

Adresa: ........................................................................................................................................

Kontakt:........................................................................................................................................

PLATILAC

Ime prezime/Naziv tvrtke .................................................................................................................

JIB/IB: ................................................................. PDV/PIB: …...................................................

Adresa: …......................................................................................................................................

TROŠKOVI
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MJESTO I DATUM PODNOŠENJA ZAHTJEVA: …….........................................................................

POTPIS PODNOSITELJA ZAHTJEVA: ….........................................................................................

POTPIS DJELATNIKA / ISPITIVAČA: …..........................................................................................


Podnositelj zahtjeva svojim potpisom daje suglasnost sa svim navedenim podacima

C-O-01.00
Datum: 20.10.2020
Strana 1 od 1

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