POTVRDA O AKTIVNOSTIMA

FORMULAIRE DATTESTATION DACTIVITS - ATTESTATION OF ACTIVITIES

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Naziv firme / Nom de lentreprise / Name of the undertaking:

Ulica, potanski broj, mjesto, / Rue, code postal, ville / Street adress, postal code, city:
Drava / Pays / Country: Bosna i Hercegovina
Telefon / Tlphone / Phone: + 387
Fax / Tlfax / Fax: + 387
Adresa elektronske pote / Adresse courrier lectronique/e-mail address:

Ja, nie potpisani / Le soussign / I, the undersign:

6. Ime i prezime / Nom et prnom / First name and last name:
7. Funkcija u firmi / Fonction dans lentreprise / Position in the undertaking:
Izjavljujem da voza / dclare que le conducteur / declare that the driver
8. Ime i prezime / Nom et prnom / First name and last name:
9. Datum roenja / Date de naissance: (jour/mois/anne)/Date of birth (day/month/year): //
10. Br. vozake dozvole ili line karte ili pasoa / Numro du permis de conduire ou de la carte didentit
ou du passeport/Driving licence or identity card or passport number Vozaka dozvola:
11. Zaposlen u firmi od (dan/mjesec/godina) / qui a commanc de travailler dans l'entreprise le (jour/
mois/anne) / who has started to work at the undertaking on (day/month/year): //
Za period / au cours de la priode / for the period
12. Od : / du (heure/jour/mois/anne) / from (hour/day/month/year): ///
13. Do : / au (heure/jour/mois/anne )/ to (hour/day/month/year: ///
14.
Bio na bolovanju / tait en cong de maladie / was on sick leave.
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Bio na godinjem odmoru / tait en cong annuel / was on annual leave.
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Ostali izostanci / tait en cong ou repos / was on leave or rest.
17.
Upravljao vozilom izuzetim iz primjene Zakona o radnom vremenu, obaveznim odmorima mobilnih radnika i
ureajima za evidentiranje u cestovnom prijevozu, Uredbe (EC)561/2006 AETR / conduisait un vhicule exclu du
champ dapplication du rglement (CE) 561/2006 ou de lAETR ***/ drove a vehicle exempted from the scope of
Regulation (EC) 561/2006 or the AETR.
18.
Obavljao druge poslove osim upravljanja vozilom / effectuait autre travail que la conduite / performed other work
than driving.
19.
Bio na raspolaganju / tait disponible / was available.
20.
Mjesto / Lieu / Place: Datum / Date / Date: //.
Potpis / Signature / Signature: __________________________________________
21. Ja, voza , potvrujem da nisam upravljao vozilom obuhvaenim primjenom Zakona o radnom vremenu,
obaveznim odmorima mobilnih radnika i ureajima za evidentiranje u cestovnom prijevozu, Uredbe (EC)561/2006
AETR tokom gornjeg perioda. / Le soussign, conducteur, confirme ne pas avoir conduit un vhicule relevant du champ
dapplication du rglement (CE) 561/2006 ou de lAETR au cours de la priode susmentionne. (I, the driver, confirm that I
have not been driving a vehicle falling under the scope of Regulation (EC) 561/2006 or the AETR during the period
mentioned above).
22. Mjesto / Lieu / Place:

Datum /Date / date: //.

Potpis vozaa / Signature du conducteur / signature of the driver: _________________________________________

ISPUNITI U DIGITALNOJ FORMI ( ISPIS NA PISAU )
Ispunjava se tampanim latinskim slovima i potpisuje prije polaska / remplir en dactylographie en caractres latins et signer avant tout voyage / To be
filled in by typing in Latin characters and signed before a journey
uvati sa originalnim zapisima tahografskog ureaja / joindre aux enregistrements de lappareil de contrle qui doivent tre conservs/To be kept with the
original control device records wherever they are required to be kept
KRIVI NAVODI PREDSTAVLJAJU PREKRAJ ! / LES FAUSSES ATTESTATIONS CONSTITUENT UNE INFRACTION/FALSE ATTESTATIONS
CONSTITUTE AN INFRINGEMENT!