POTVRDAO AKTIVNOSTIMA - FORMULAIRED'ATTESTATIOND'ACTIVITES- ATTESTATION OT-ACTIVITIES l. Naziv tvftke / Nontde I'entrepri.se I Numeof lhe undertoking - MIKAN-PROM d.o.o. 2 Ulica' poStanski I Rue,coclepo.stal,t,illelstreet aclre.ss, broj. rn-iesto postalcocle,cilv- Bijeljina,76300 Modran Drlava I Pu.t,.s I Country- Bosnai Hercegovina 3. TelefonI Telephone I Phone- 0038765983256 4. Faksi Tele/ax I Fsx- 00J875555050 5. Adresaelektronsl<e - [email protected] poste/ Adre.sse courrier electroniqueI Entctilacldres.s Ja, nii.e potpisani I Le soussigtrdI I, the undersigned 6 l r n ei p r e z i m et N o n te t p r c n o m , ' F i r s tc t n dl c r . ynlc t m e- M i h a n p a r a d e n o v i d 7. Funkci.ja u tvrtciI Foncliontlun.sI'enlrepri,se,t Positionin the undertukinp- Direktor fzjavljujem da vozat I ddclureque le conducleur I declarelhut the tlriver 8. IrneiprezimeI Nontet prenontI Fir.s!and la.stnutne- Radomir Stojanovi( 9. DaturnrodeniaI Date de naissance (lour/moi.s/annde) I Date o/'birth (da.y/nonth/vear)-02.08. 1965. l0 Br vozadkeclozvoleili osobneisk. ili putovniceI Numdrodu permisde concluireou clela c'ertecl'iclentite ott clupa5.sepsr/ I Driving )rivtng licencc licenccor identitl identitl card pa.ssportnunlbqr- Osobna iskaznica- l0GBM6058 card rtr pa.ssport I l. Zaposlenu tvrlki od (daninr.jeseclgodina) , QulLr c:t tntnt ut7c tj tl c:ontrnutTc? de e !!rut,ctiller r uy o i | | er tl tlans u ns l'l'entr en I reytri,se I c (j o ut.,,nto i s urtnee) i IL'ho hu.s sturlecl Io tyotk ut the undertukiugon (clut,,ttronthtt'eur1- Q9. 02.2011. Za razdoblje I uu conrs de la pdriode l.for the iotl l2 Od / du (heureijour/ntoi.s/annte) I from (hour/, rv/ntonth/vearl - I 4 :30:00 t9. 12.2012. - 07:30:00 29. 12.2012. I 3 Do / an (heure/jour/ntois/anndeI to (hour/, 'ntonth/ttear) 14.Bio na bolovanjuI dtait en congdde moladieI a s o n . s i c kl e a y e - N E 1 5 .B i o n a g o d i S n j e rord m o r uI i t a i t e n ( ' o n g e( I v,o.son annual/eave - NE l6. Ostali izostanciI etuit en L'on!:eoLttcpos I trus tn leuyc rtr t'esl - DA l 7 U p r a v l l a ov o z i l o n ti z u z e t i r ni z p l i r nj e n eU r e (EC)561/2006 AETR i condui.saitttn vihicule esclu thr c'hunp t\'upplicution thr riglenrent(('E) 56l,l()06 ou tla | '4 ETR,' tlt.cn,e u icle cxentptcd of Regulution(EC) 561,'2006or the.46fR - NE fi'ontthe sc'r,tpe 1 8 .O b a v l j a od r u g ep o s l o v eo s i mu p r a v l . j a n vj ao z i m I e/fec'tuaitautre Iravctilcluela c'onduiteI pejbrmed other vt,ork!han driving NE lable - NE ate - 29. 12.2012. 21. Ja.voza( Radomir Stoj'irnn,ui#pofvrdLrjent dalrrisarn upravl-iao vozilonrobuhvaceuinr primjenornuredbe(EC),56 l/2006 AETR tijekorlgor.n.|egrazdobIjaiLe.sotts'signe't'ont|ut'|eut rdglentent(CE) 561/2006ou clel'AETR qu coltr.tde la piriode.su.vmentionnee i I, the clriver,confirn that I hcrvenor heendriving u vehicle/ttlling underthe scopeo/-Regulation(EC) 561/2006or the AETR cluringthe perioclmentioneclabcn,e) 2 0 M j e s t oI l i e u I p l a c e - M o d r a n D a t u mI d a t eI d a t e - 2 9 . l Z . 2 0 l Z . PotpisvozadaI signaturedu conducteurLsignatureof the drit;er I S P U N I T IU D I G I T A L N O JF O R M I ( I S P I SN A P I S A E U ) c h a r a c t e r sa n d s i g n e d b e f b r ea 1 o u r n e r d e r i c e r e c o r d sr r h e r r ' r c rt h e r a r c r c r l u r r e dt o L r ck c p t K R l v l N A V o D I P R I - . D S l A V t . r A l tl ' t < t K l < i n . t L t r s l ^ t s s t r s A r - l E S T A f t o N S C o N S l i u E N r u N E T N F I I A C I - l o N I N l r l ( l N ( i t r M F - NI l /FAtsF.ATff-srAiIoNSCoNS-tlfut-t:,AN
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