POTVRDA O AKTIVNOSTIMA - FORMULAIRE D'ATTESTATION D'ACTIVITES - ATTESTATION OF ACTIVITIES l. Naziv tvrtke/ Nom de I'entrepriseI Name of the undertaking- MIKAN-PROM d.o.o. broj, mjestoI Rue,codepostal,ville I Streetadress,postal code,cifl - Bijeljina, 76300Modran 2. Ulica, poStanski DrLavalPayslCountry - Bosnai Hercegovina I Phone- 0038765983256 3. TelefonI Tdldphone 4. FaksI TdldfaxI Far - 003875555050 5. Adresaelektronskepoite I Adressecourrier dlectroniqueI Email address- [email protected] Ja, nii,epotpisaniI Le soussigndI I, the undersigned 6. Ime i prezimeI Nom et prdnomI First and last name- Mikan Paraalenovid 7. Funkcijau tvrtci I FonctiondansI'entrepriseI Positionin the undertaking- Direktor Izjavljujem da vozadI ddcldreque le conducteurI declarethat the driver 8. Ime i prezimeI Nomet prdnomI First and last name- Radomir Stojanovi6 -02.08. 1965. I Date of birth (day/month/year) 9. DatumrodenjaI Date d.enaissance'(our/mois/annde) 10. Br. vozadkedozvoleili osobneisk. ili putovniceI Numdrodu permisde conduireou de la carte d'identitdou du passeportI Driving l.icenceor identitycard or passportnumber- Osobna iskaznica- 10G8M6058 I Qui a commancdde travailler dansl'entreprisele (jour/mois/annde) I Whohasstarted I l. Zaposlenu tvrtki od (dan/mjesec/godina) - 09. 02.2011. to work at the undertakingon (day/month/year) Za razdoblje I au cours de la pdriode / for the period - l6:00:00 13. 02. 2013. I from (hour/day/month/year) 12.Od I du (heure/jotr/mois/annde) - 07:30:00 18. 02. 2013. I 3, Do / au (heure/jour/mois/annde) I to (hour/day/month/year) 14. Bio na bolovanjuI dtait en congdde maladie/ was on sick leave- NE 15. Bio na godi5njemodmoruI dtait en congdannuelI was on annualleave- NE I dtaiten congdou reposlwa.son leaveor rest -DA 16.Ostaliizostanci 17.Upravljaovozilomizuzelimiz primjeneUredbe(EC)561/2006 AETR i conduisaitun vdhiculeexcludu champd'applicationdu rdglement(CE) 561/2006ou de I'AETR I drove avehicle exemptedfromthe scopeof Regulation(EC) 561/2006or thelEfR - NE autre travail que la conduiteI performedother work than driving 18.Obavljaodrugeposloveosim upravljanjavozilom I e.ffectuait NE 19 Bio na raspolaganj u I dtait disponibleI was available- NE 20. MjestoI lieu I place- Modran date- 78.02.2013. Potpis/ signature/ signature cl 2l . Ja, vozad,Radomir Stoja primjenomuredbe(EC)561/2006 isamupravljaovozilomobuhvadenim AETR tijekom gornjegrazdoblja.I Le ur, confirme ne pas avoir conduit un vdhicule relevant du chantp d'application du rdglement(CE) 561/2006ou de I'AETR au cours de la p€riodesusmentionnde. I I, the driver, confirm that I havenot beendriving a vehiclefalling underthe scopeof Regulation(EC) 561/2006 or the AETRduring theperiod mentionedabove). 20. Mjesto/ lt:eu/ place - Modran Datum/ date/ date- 18.02,2013. PotpisvozadaI signaturedu conducteurI signatureofthe driver 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 C U ) characters andsrgnedbeforea lourney Cuvatisaoriginalnimzapisimatahograt-skog devicerecordswherevertheyarerequiredto be kept K R I V I N A V O D IP R E D S T A V L J A I P UR E K R S A J/ IL E S F A U S S E S A T T E S T A T I O NC S O N S T I T U E NU T N E I N F R A C T I O N/!F A L S E A T T E S T A T I o N S C o N S T I T U T EA N INFRINGEMENTI , http://www mikan-prom.com/kategorija.php?naslov=Transport&kategorija:4&p:PotvrdaVo20oo/o20aktivnosti'rna%20/%20ATTES&icl-27
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