Указ Губернатора Орловской области от 06.11.2012 № 455

     
                              Заявление
  о переоформлении лицензии на осуществление деятельности по обороту
     наркотических средств, психотропных веществ и их прекурсоров
               культивированию наркосодержащих растений
     
Регистрационный N________________ лицензии от _______________ 20__г.,

предоставленной_______________________________________________________
                 (наименование лицензирующего органа)

I. В связи с:
__* реорганизацией юридического лица в форме преобразования;
__* реорганизацией юридического лица в форме слияния;
__* изменением наименования юридического лица;
__* изменением адреса места нахождения юридического лица;
__* изменением   адреса   места   осуществления   юридическим    лицом
лицензируемого вида деятельности при фактически неизменном месте
осуществления деятельности.
|———————|————————————————————————————|——————————————————————————————————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————|
|   N   |    Сведения о заявителе    |                          Сведения о лицензиате/                          |            Новые сведения о лицензиате или его правопреемнике            |
|       |                            |                               лицензиатах                                |                                                                          |
|———————|————————————————————————————|——————————————————————————————————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————|
|   1   |             2              |                                    3                                     |                                    4                                     |
|———————|————————————————————————————|——————————————————————————————————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————|
|  1.   | Организационно-правовая    |                                                                          |                                                                          |
|       | форма и полное             |                                                                          |                                                                          |
|       | наименование юридического  |                                                                          |                                                                          |
|       | лица/фамилия, имя и        |                                                                          |                                                                          |
|       | (в случае, если имеется)   |                                                                          |                                                                          |
|       | отчество, данные           |                                                                          |                                                                          |
|       | документа, удостоверяющего |                                                                          |                                                                          |
|       | личность индивидуального   |                                                                          |                                                                          |
|       | предпринимателя            |                                                                          |                                                                          |
|———————|————————————————————————————|——————————————————————————————————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————|
|  2.   | Сокращенное наименование   |                                                                          |                                                                          |
|       | юридического лица          |                                                                          |                                                                          |
|       | (в случае, если имеется)   |                                                                          |                                                                          |
|———————|————————————————————————————|——————————————————————————————————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————|
|  3.   | Фирменное наименование     |                                                                          |                                                                          |
|       | юридического лица          |                                                                          |                                                                          |
|       | (в случае, если имеется)   |                                                                          |                                                                          |
|———————|————————————————————————————|——————————————————————————————————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————|
|  4.   | Адрес местонахождения      |                                                                          |                                                                          |
|       | юридического лица/адрес    |                                                                          |                                                                          |
|       | места жительства           |                                                                          |                                                                          |
|       | индивидуального            |                                                                          |                                                                          |
|       | предпринимателя            |                                                                          |                                                                          |
|———————|————————————————————————————|——————————————————————————————————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————|
|  5.   | Государственный            |                                                                          |                                                                          |
|       | регистрационный номер      |                                                                          |                                                                          |
|       | записи о создании          |                                                                          |                                                                          |
|       | юридического               |                                                                          |                                                                          |
|       | лица/государственный       |                                                                          |                                                                          |
|       | регистрационный номер      |                                                                          |                                                                          |
|       | записи о государственной   |                                                                          |                                                                          |
|       | регистрации                |                                                                          |                                                                          |
|       | индивидуального            |                                                                          |                                                                          |
|       | предпринимателя            |                                                                          |                                                                          |
|       |                            |                                                                          |                                                                          |
|———————|————————————————————————————|——————————————————————————————————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————|
|  6.   | Данные документа,          | Выдан_________________________________________________                   | Выдан_________________________________________________                   |
|       | подтверждающего факт       |                        (орган, выдавший документ)                        |                        (орган, выдавший документ)                        |
|       | внесения сведений о        |                                                                          |                                                                          |
|       | юридическом лице в Единый  | Дата выдачи_______                                                       | Дата выдачи_______                                                       |
|       | государственный реестр     | __________________Бланк:                                                 | __________________Бланк:                                                 |
|       | юридических лиц/сведений   | серия_______                                                             | серия_______                                                             |
|       | об индивидуальном          | N________________                                                        | N ________________                                                       |
|       | предпринимателе - в Единый |                                                                          |                                                                          |
|       | государственный реестр     | Адрес___________________________________________________________________ | Адрес___________________________________________________________________ |
|       | индивидуальных             |                                                                          |                                                                          |
|       | предпринимателей, с        |                                                                          |                                                                          |
|       | указанием адреса места     |                                                                          |                                                                          |
|       | нахождения органа,         |                                                                          |                                                                          |
|       | осуществившего             |                                                                          |                                                                          |
|       | государственную            |                                                                          |                                                                          |
|       | регистрацию                |                                                                          |                                                                          |
|———————|————————————————————————————|——————————————————————————————————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————|
|  7.   | Данные документа,          | Выдан________________________________________________________________________                                                                       |
|       | подтверждающего факт       |                                                             (орган, выдавший документ)                                                              |
|       | внесения соответствующих   | Дата выдачи____________________________                                                                                                             |
|       | изменений в Единый         | _______________________________________                                                                                                             |
|       | государственный реестр     |                                                                                                                                                     |
|       | юридических лиц/Единый     | Бланк: серия_________N_________________                                                                                                             |
|       | государственный реестр     |                                                                                                                                                     |
|       | индивидуальных             | Адрес________________________________________________________________________                                                                       |
|       | предпринимателей           |                                                                                                                                                     |
|———————|————————————————————————————|——————————————————————————————————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————|
|  8.   | Идентификационный номер    |                                                                          |                                                                          |
|       | налогоплательщика          |                                                                          |                                                                          |
|———————|————————————————————————————|——————————————————————————————————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————|
|  9.   | Данные документа о         | Выдан_________________________________________________                   | Выдан_________________________________________________                   |
|       | постановке лицензиата на   |                        (орган, выдавший документ)                        |                        (орган, выдавший документ)                        |
|       | учет в налоговом органе    |                                                                          |                                                                          |
|       |                            | Дата выдачи_______                                                       | Дата выдачи_______                                                       |
|       |                            | __________________                                                       | __________________                                                       |
|       |                            |                                                                          |                                                                          |
|       |                            | Бланк: серия_______                                                      | Бланк: серия_______                                                      |
|       |                            | N________________                                                        | N________________                                                        |
|       |                            |                                    3                                     |                                    4                                     |
|       |                            |                                                                          |                                                                          |
|       |             2              |                                                                          |                                                                          |
|   1   |                            |                                                                          |                                                                          |
|———————|————————————————————————————|——————————————————————————————————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————|
|       |                            | Адрес_________________________________________________                   | Адрес_________________________________________________                   |
|———————|————————————————————————————|——————————————————————————————————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————|
|  10.  | Сведения о                 | ______________________________________________________________________________                                                                      |
|       | распорядительном           |                                                             (орган, принявший решение)                                                              |
|       | документе, на основании    |                                                                                                                                                     |
|       | которого произошло         | Реквизиты документа ____________________                                                                                                            |
|       | изменение адреса места     | _____________________________________________________________________________________________________________________                               |
|       | осуществления деятельности |                                                                                                                                                     |
|———————|————————————————————————————|—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  11.  | Реквизиты документа,       | N платежного                                                                                                                                        |
|       | подтверждающего факт       | поручения __________________                                                                                                                        |
|       | уплаты государственной     | Дата ______________                                                                                                                                 |
|       | пошлины за предоставление  | В размере __________                                                                                                                                |
|       | лицензии, либо иные        |                                                                                                                                                     |
|       | сведения, подтверждающие   |                                                                                                                                                     |
|       | факт уплаты указанной      |                                                                                                                                                     |
|       | государственной пошлины    |                                                                                                                                                     |
|———————|————————————————————————————|——————————————————————————————————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————|
|  12.  | Адрес (адреса) мест        |                                                                          | (адрес места осуществления лицензируемого вида деятельности)             |
|       | осуществления              |                                                                          |                                                                          |
|       | лицензируемого вида        |                                                                          | __________________                                                       |
|       | деятельности .             |                                                                          |        (указать работы и услуги согласно приложению к Положению о        |
|       | Выполняемые работы,        |                                                                          |      лицензировании деятельности по обороту наркотических средств,       |
|       | оказываемые услуги,        |                                                                          |  психотропных веществ и их прекурсоров, культивированию наркосодержащих  |
|       | составляющие деятельность  |                                                                          |     растении, утвержденному постановлением Правительства Российской      |
|       | по обороту наркотических   |                                                                          |                   Федерации от 22 декабря 2011 N 1085)                   |
|       | средств, психотропных      |                                                                          |                                                                          |
|       | веществ и их прекурсоров,  |                                                                          |                                                                          |
|       | культивированию            |                                                                          |                                                                          |
|       | наркосодержащих растений   |                                                                          |                                                                          |
|———————|————————————————————————————|——————————————————————————————————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————|
|  13.  | Номер телефона,            |                                                                                                                                                     |
|       | в случае, если имеется     |                                                                                                                                                     |
|       | адрес электронной почты    |                                                                                                                                                     |
|———————|————————————————————————————|—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  14.  | Форма получения            | __* На бумажном носителе лично.                                                                                                                     |
|       | переоформленной лицензии   | __* На бумажном носителе направить заказным почтовым отправлением с уведомлением о вручении.                                                        |
|       |                            | __* В форме электронного документа.                                                                                                                 |
|———————|————————————————————————————|—————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
__* Нужное отметить

     II. В связи с:
__* изменением   адресов   мест  осуществления   лицензируемого   вида
деятельности;
__* изменением   перечня   выполняемых   работ,   оказываемых   услуг,
составляющих  лицензируемый вид  деятельности,  ранее не  указанных  в
лицензии;
__* прекращением деятельности по одному адресу или нескольким  адресам
мест осуществления деятельности, указанным в лицензии;
__* прекращением деятельности выполняемых  работ и оказываемых  услуг,
составляющих лицензируемый вид деятельности;
__* истечением   срока   действия   лицензии   (лицензий)   на    виды
деятельности,  наименования  которых   изменены,  не  содержащей   (не
содержащих) перечня выполняемых работ, оказываемых услуг, составляющих
лицензируемый вид деятельности.

|——————|——————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  1.  | Организационно-правовая форма и полное       |                                                                                                                                      |
|      | наименование юридического лица/фамилия, имя  |                                                                                                                                      |
|      | и (в случае, если имеется) отчество, данные  |                                                                                                                                      |
|      | документа, удостоверяющего личность          |                                                                                                                                      |
|      | индивидуального предпринимателя              |                                                                                                                                      |
|——————|——————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  2.  | Сокращенное наименование юридического лица   |                                                                                                                                      |
|      | (в случае, если имеется)                     |                                                                                                                                      |
|——————|——————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  3.  | Фирменное наименование юридического лица     |                                                                                                                                      |
|      | (в случае, если имеется)                     |                                                                                                                                      |
|——————|——————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  4.  | Адрес места нахождения юридического          |                                                                                                                                      |
|      | лица/адрес места жительства индивидуального  |                                                                                                                                      |
|      | предпринимателя                              |                                                                                                                                      |
|——————|——————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  5.  | Государственный регистрационный номер записи |                                                                                                                                      |
|      | о создании юридического лица/государственный |                                                                                                                                      |
|      | регистрационный номер записи о               |                                                                                                                                      |
|      | государственной регистрации индивидуального  |                                                                                                                                      |
|      | предпринимателя                              |                                                                                                                                      |
|——————|——————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  6.  | Идентификационный номер налогоплательщика    |                                                                                                                                      |
|——————|——————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  7.  | Номер телефона, адрес электронной почты в    |                                                                                                                                      |
|      | (случае, если имеется)                       |                                                                                                                                      |
|——————|——————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  8.  | Форма получения переоформленной лицензии     | __* На бумажном носителе лично.                                                                                                      |
|      |                                              | __* На бумажном носителе направить заказным почтовым отправлением с уведомлением о вручении.                                         |
|      |                                              | __* В форме электронного документа.                                                                                                  |
|——————|——————————————————————————————————————————————|——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
|  9.  | __* в связи с изменением адресов мест осуществления лицензируемого вида деятельности                                                                                                |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 9.1. | Сведения о новых адресах мест      |                                         ______________________________________________________________                                         |
|      | осуществления лицензируемого вида  |                                          (адрес места осуществления лицензируемого вида деятельности)                                          |
|      | деятельности.                      |                                                                                                                                                |
|      | Сведения о новых работах           |                                               _________________________________________________                                                |
|      | (услугах), которые лицензиат       |                            _______________________________________________________________________________________                             |
|      | намерен выполнять при              |                           (указать работы и услуги согласно приложению к Положению о лицензировании деятельности по                            |
|      | осуществлении деятельности по      |                     обороту наркотических средств, психотропных веществ и их прекурсоров, культивированию наркосодержащих                      |
|      | обороту наркотических средств,     |                    растении, утвержденному постановлением Правительства Российской Федерации от 22 декабря 2011 года N 1085)                   |
|      | психотропных веществ и их          |                                                                                                                                                |
|      | прекурсоров, культивированию       |                                                                                                                                                |
|      | наркосодержащих растений           |                                                                                                                                                |
|      | (при выполнении работ (оказании    |                                                                                                                                                |
|      | услуг), предусмотренных пунктами   |                                                                                                                                                |
|      | 2, 3, 11, 15, 16, 23, 27, 28, 39,  |                                                                                                                                                |
|      | 43, 44, 55, 63 приложения к        |                                                                                                                                                |
|      | Положению о лицензировании         |                                                                                                                                                |
|      | деятельности по обороту            |                                                                                                                                                |
|      | наркотических средств,             |                                                                                                                                                |
|      | психотропных веществ и их          |                                                                                                                                                |
|      | прекурсоров, культивированию       |                                                                                                                                                |
|      | наркосодержащих растений,          |                                                                                                                                                |
|      | утвержденному постановлением       |                                                                                                                                                |
|      | Правительства Российской Федерации |                                                                                                                                                |
|      | от 22 декабря 2011 года N 1085 - с |                                                                                                                                                |
|      | указанием конкретных наркотических |                                                                                                                                                |
|      | средств и психотропных веществ,    |                                                                                                                                                |
|      | внесенных в списки I-III перечней, |                                                                                                                                                |
|      | и прекурсоров, внесенных в список  |                                                                                                                                                |
|      | I и таблицу I списка IV перечня)   |                                                                                                                                                |
|      |                                    |                                                                                                                                                |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 9.2  | Сведения о документах,             | Реквизиты документов:___________                                                                                                               |
|      | подтверждающих наличие у           | _______________________________                                                                                                                |
|      | лицензиата на праве собственности  |                                                                                                                                                |
|      | или на ином законном основании     |                                                                                                                                                |
|      | соответствующих установленным      |                                                                                                                                                |
|      | требованиям и необходимых для      |                                                                                                                                                |
|      | осуществления деятельности по      |                                                                                                                                                |
|      | обороту наркотических средств,     |                                                                                                                                                |
|      | психотропных веществ и их          |                                                                                                                                                |
|      | прекурсоров, культивированию       |                                                                                                                                                |
|      | наркосодержащих растений помещений |                                                                                                                                                |
|      | и земельных участков, права на     |                                                                                                                                                |
|      | которые зарегистрированы в Едином  |                                                                                                                                                |
|      | государственном реестре прав на    |                                                                                                                                                |
|      | недвижимое имущество и сделок с    |                                                                                                                                                |
|      | ним                                |                                                                                                                                                |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 9.3  | Сведения о наличии заключений      | Реквизиты я органов по контролю за оборотом наркотических средств и психотропных веществ о соответствии объектов                               |
|      | органа по контролю за оборотом     |      и помещений, в которых осуществляются деятельность, связанная с оборотом наркотических средств, психотропных                              |
|      | наркотических средств и            |       веществ и внесенных в прекурсоров, и (или) культивирование наркосодержащих растений, установленным требованиям                           |
|      | психотропных веществ,              |      к оснащению этих объектов и помещений инженерно-техническими средствами охраны                                                            |
|      | предусмотренных абзацем третьим    |                                                                                                                                                |
|      | пункта 3 статьи 10 Федерального    |                                                                                                                                                |
|      | закона "О наркотических средствах  |                                                                                                                                                |
|      | и психотропных веществах"          |                                                                                                                                                |
|      |                                    |                                                                                                                                                |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 9.4  | Сведения о сертификате             | Реквизиты сертификата:___________                                                                                                              |
|      | специалиста, подтверждающем        | _________________________________                                                                                                              |
|      | соответствующую профессиональную   |                                                                                                                                                |
|      | подготовку руководителя            |                                                                                                                                                |
|      | подразделения юридического лица,   |                                                                                                                                                |
|      | расположенного по новому адресу,   |                                                                                                                                                |
|      | при осуществлении оборота          |                                                                                                                                                |
|      | наркотических средств и            |                                                                                                                                                |
|      | психотропных веществ, внесенных в  |                                                                                                                                                |
|      | - перечней, прекурсоров, внесенных |                                                                                                                                                |
|      | в перечня, и наркосодержащих       |                                                                                                                                                |
|      | растений                           |                                                                                                                                                |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 9.5  | Реквизиты документа,               | N платежного                                                                                                                                   |
|      | подтверждающего факт уплаты        | поручения __________________                                                                                                                   |
|      | государственной пошлины за         | Дата ______________                                                                                                                            |
|      | предоставление лицензии, либо иные | В размере __________                                                                                                                           |
|      | сведения, подтверждающие факт      |                                                                                                                                                |
|      | уплаты указанной государственной   |                                                                                                                                                |
|      | пошлины                            |                                                                                                                                                |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 10.  | __* в связи с изменением перечня выполняемых работ, оказываемых услуг, составляющих лицензируемый вид деятельности, ранее не указанных в лицензии                                   |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 10.1 | Сведения о новых адресах мест      | ____________________________________________________________________________________________________________________________                   |
|      | осуществления лицензируемого вида  |                                          (адрес места осуществления лицензируемого вида деятельности)                                          |
|      | деятельности.                      |                      ___________________________________________________________________________________________________                       |
|      | Сведения о новых работах           |                                           (указать работы и услуги согласно приложению к Положению о                                           |
|      | (услугах), которые лицензиат       |                                         лицензировании деятельности по обороту наркотических средств,                                          |
|      | намерен выполнять при              |                         психотропных веществ и их прекурсоров, культивированию наркосодержащих растении, утвержденному                         |
|      | осуществлении деятельности по      |                               постановлением Правительства Российской Федерации от 22 декабря 2011 года N 1085)                                |
|      | обороту наркотических средств,     |                                                                                                                                                |
|      | психотропных веществ и их          |                                                                                                                                                |
|      | прекурсоров, культивированию       |                                                                                                                                                |
|      | наркосодержащих растений           |                                                                                                                                                |
|      | (при выполнении работ (оказании    |                                                                                                                                                |
|      | услуг), предусмотренных пунктами   |                                                                                                                                                |
|      | 2, 3, 11, 15, 16, 23, 27, 28, 39,  |                                                                                                                                                |
|      | 43, 44, 55, 63 приложения к        |                                                                                                                                                |
|      | Положению о лицензировании         |                                                                                                                                                |
|      | деятельности по обороту            |                                                                                                                                                |
|      | наркотических средств,             |                                                                                                                                                |
|      | психотропных веществ и их          |                                                                                                                                                |
|      | прекурсоров, культивированию       |                                                                                                                                                |
|      | наркосодержащих растений,          |                                                                                                                                                |
|      | утвержденному постановлением       |                                                                                                                                                |
|      | Правительства Российской Федерации |                                                                                                                                                |
|      | от 22 декабря 2011 года N 1085 - с |                                                                                                                                                |
|      | указанием конкретных наркотических |                                                                                                                                                |
|      | средств и психотропных веществ,    |                                                                                                                                                |
|      | внесенных в списки I-III перечней, |                                                                                                                                                |
|      | и прекурсоров, внесенных в список  |                                                                                                                                                |
|      | I и таблицу I списка IV перечня)   |                                                                                                                                                |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 10.2 | Сведения о документах,             | Реквизиты документов:___________                                                                                                               |
|      | подтверждающих наличие у           |                                                                                                                                                |
|      | лицензиата на праве собственности  |                                                                                                                                                |
|      | или на ином законном основании     |                                                                                                                                                |
|      | соответствующих установленным      |                                                                                                                                                |
|      | требованиям и необходимых для      |                                                                                                                                                |
|      | осуществления деятельности по      |                                                                                                                                                |
|      | обороту наркотических средств,     |                                                                                                                                                |
|      | психотропных веществ и их          |                                                                                                                                                |
|      | прекурсоров, культивированию       |                                                                                                                                                |
|      | наркосодержащих растений помещений |                                                                                                                                                |
|      | и земельных участков, права на     |                                                                                                                                                |
|      | которые зарегистрированы в Едином  |                                                                                                                                                |
|      | государственном реестре прав на    |                                                                                                                                                |
|      | недвижимое имущество и сделок с    |                                                                                                                                                |
|      | ним (указать при намерении         |                                                                                                                                                |
|      | выполнять работу (оказывать услугу |                                                                                                                                                |
|      | по культивированию наркосодержащих |                                                                                                                                                |
|      | растений), ранее не указанную в    |                                                                                                                                                |
|      | лицензии)                          |                                                                                                                                                |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 10.3 | Сведения о наличии заключений      | Реквизиты я органов по контролю за оборотом наркотических средств и психотропных веществ о соответствии                                        |
|      | органа по контролю за оборотом     |      объектов и помещений, в которых осуществляются деятельность, связанная с оборотом наркотических средств,                                  |
|      | наркотических средств и            |      психотропных веществ и внесенных в прекурсоров, и (или) культивирование наркосодержащих растений,                                         |
|      | психотропных веществ,              |      установленным требованиям к оснащению этих объектов и помещений инженерно-техническими средствами охраны                                  |
|      | предусмотренных абзацем третьим    | ______________________________________________________________                                                                                 |
|      | пункта 3 статьи 10 Федерального    |                                                                                                                                                |
|      | закона "О наркотических средствах  |                                                                                                                                                |
|      | и психотропных веществах" (указать |                                                                                                                                                |
|      | при намерении выполнять работу     |                                                                                                                                                |
|      | (оказывать услугу по               |                                                                                                                                                |
|      | культивированию наркосодержащих    |                                                                                                                                                |
|      | растений), ранее не указанную в    |                                                                                                                                                |
|      | лицензии)                          |                                                                                                                                                |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 10.4 | Реквизиты документа,               | N платежного                                                                                                                                   |
|      | подтверждающего факт уплаты        | поручения __________________                                                                                                                   |
|      | государственной пошлины за         | Дата ______________                                                                                                                            |
|      | предоставление лицензии, либо иные | В размере __________                                                                                                                           |
|      | сведения, подтверждающие факт      |                                                                                                                                                |
|      | уплаты указанной государственной   |                                                                                                                                                |
|      | пошлины                            |                                                                                                                                                |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 11.  | __* в связи с прекращением деятельности по одному адресу или нескольким адресам мест осуществления деятельности, указанным в лицензии                                               |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 11.1 | Адрес (адреса) мест осуществления  | ______________________________________________________________                                                                                 |
|      | лицензируемого вида деятельности,  |      (адрес места осуществления лицензируемого вида деятельности)                                                                              |
|      | на которых лицензиат прекращает    |                                                                                                                                                |
|      | деятельность.                      | _________________________________________________________                                                                                      |
|      | Выполняемые работы, оказываемые    |      _________________________________________________________________________                                                                 |
|      | услуги, составляющие деятельность  |      (указать работы и услуги)                                                                                                                 |
|      | по обороту наркотических средств,  |                                                                                                                                                |
|      | психотропных веществ и их          |                                                                                                                                                |
|      | прекурсоров, культивированию       |                                                                                                                                                |
|      | наркосодержащих растений           |                                                                                                                                                |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 11.2 | Дата фактического прекращения      |                                                                                                                                                |
|      | деятельности по одному адресу или  |                                                                                                                                                |
|      | нескольким адресам мест            |                                                                                                                                                |
|      | осуществления деятельности,        |                                                                                                                                                |
|      | указанным в лицензии               |                                                                                                                                                |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 11.3 | Реквизиты документа,               | N платежного                                                                                                                                   |
|      | подтверждающего факт уплаты        | поручения __________________                                                                                                                   |
|      | государственной пошлины за         | Дата ______________                                                                                                                            |
|      | предоставление лицензии, либо иные | В размере __________                                                                                                                           |
|      | сведения, подтверждающие факт      |                                                                                                                                                |
|      | уплаты указанной государственной   |                                                                                                                                                |
|      | пошлины                            |                                                                                                                                                |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 12.  | __* в связи с прекращением деятельности по выполнению работ, оказанию услуг, составляющих лицензируемый вид деятельности и указанных в лицензии                                     |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 12.1 | Выполняемые работы, оказываемые    | __________________________________________________________________________________                                                             |
|      | услуги, которые лицензиат          |      (указать работы и услуги)                                                                                                                 |
|      | прекращает исполнять при           | (адрес места осуществления лицензируемого вида деятельности)                                                                                   |
|      | осуществлении деятельности по      |                                                                                                                                                |
|      | обороту наркотических средств,     |                                                                                                                                                |
|      | психотропных веществ и их          |                                                                                                                                                |
|      | прекурсоров, культивированию       |                                                                                                                                                |
|      | наркосодержащих растений.          |                                                                                                                                                |
|      | Адрес (адреса) мест осуществления  |                                                                                                                                                |
|      | лицензируемого вида деятельности   |                                                                                                                                                |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 12.2 | Дата фактического прекращения      |                                                                                                                                                |
|      | лицензиатом выполнения указанных в |                                                                                                                                                |
|      | лицензии работ, услуг              |                                                                                                                                                |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|
| 12.3 | Реквизиты документа,               | N платежного                                                                                                                                   |
|      | подтверждающего факт уплаты        | поручения __________________                                                                                                                   |
|      | государственной пошлины за         | Дата ______________                                                                                                                            |
|      | предоставление лицензии, либо иные | В размере __________                                                                                                                           |
|      | сведения, подтверждающие факт      |                                                                                                                                                |
|      | уплаты указанной государственной   |                                                                                                                                                |
|      | пошлины                            |                                                                                                                                                |
|——————|————————————————————————————————————|————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————|