REPUBLIKA HRVATSKA MINISTARSTVO UNUTARNJIH POSLOVA

REPUBLIC OF CROATIA MINISTRY OF THE INTERIOR

OBRAZAC 3a FORM 3a

PRIJAMNI PEAT STAMP OF RECEIPT

POLICIJSKA UPRAVA POLICE ADMINISTRATION POLICIJSKA POSTAJA POLICE STATION

ZAHTJEV / APPLICATION
za izdavanje poslovne dozvole strancu / for issuing a business permit to an alien
1. Osniva vlastitog trgovakog drutva u RH/ DA/ NE/ Founder of a self-trading company in RC YES NO Naziv tvrtke/ Name of company Sjedite i adresa/ Headquarters and address Registarski broj u Hrvatskom zavodu za zdravstveno osiguranje/ Registration number at the Croatian Health Insurance Office ifra djelatnosti/ OIB Code of activity Razdoblje za koje se zahtijeva poslovna dozvola od/ Period for which a business permit is required from 2. Obrtnik u RH/ DA/ NE/ Craftsman in RC YES NO Naziv obrta/ Name of craft Sjedite i adresa/ Headquarters and address Registarski broj u Hrvatskom zavodu za zdravstveno osiguranje/ Registration number at the Croatian Health Insurance Office ifra djelatnosti/ Code of activity Razdoblje za koje se zahtijeva poslovna dozvola od/ Period for which a business permit is required from 3. Slobodno zanimanje/ DA/ NE/ Free occupation YES NO Naziv slobodnog zanimanja/ Name of free occupation ifra djelatnosti/ Code of activity Razdoblje za koje se zahtijeva poslovna dozvola od/ Period for which a business permit is required from Struna sprema/ Professional qualifications DA/ YES NE/ NO

1. 2. 3. 4. 5.

do to

1. 2. 3. 4. 5.

do to

1. 2. 3. 4.

do to

4. Pruatelj usluga u ime inozemnog poslodavca/ Provider of services on behalf of a foreign employer 1. Naziv tvrtke u RH/ Name of company in RC 2. Sjedite i adresa/ Headquarters and address

3. Registarski broj u Hrvatskom zavodu za zdravstveno osiguranje/ Registration number at the Croatian Health Insurance Office 4. ifra djelatnosti/ OIB Code of activity 5. Naziv inozemnog poslodavca, sjedite i adresa/ Name of a foreign employer, headquarters and address 6. Razdoblje za koje se zahtijeva poslovna dozvola od/ Period for which a business permit is required from 7. Struna sprema/ Professional qualifications 8. Zanimanje/ Occupation 9. Vrsta usluge/ Type of service

do to

1. PODACI O STRANCU / DETAILS ON AN ALIEN 1. Prezime/ Surname 2. Ime/ Name 3. Ime jednog od roditelja/ Name of a parent 4. Datum roenja (dan, mjesec, godina)/ Date of birth (Day, Month, Year) 5. Spol/ M OIB* Gender M F 6. Mjesto i drava roenja Place and state of birth 7. Dravljanstvo Nationality 8. Adresa u Republici Hrvatskoj Address in the Republic of Croatia

* upisuje se ukoliko je dodijeljen / to be entered if issued

2. VAEA ISPRAVA / VALID DOCUMENT 1. Vrsta isprave/ Type of document 2. Broj/ Number 3. Datum izdavanja (dan, mjesec, godina)/ Date of issuance (Day, Month, Year) 4. Vrijedi do (dan, mjesec, godina)/ Expires (Day, Month, Year) 5. Nadleno tijelo/ Competent authority 6. Mjesto i drava izdavanja/ Place and state of issuance Zavrna izjava/Final statement: Pristajem da se svi moji osobni podaci koji se navode na ovom obrascu mogu proslijediti na provjeru nadlenim tijelima Republike Hrvatske u svrhu odluivanja o ovom zahtjevu./ I hereby agree that all my personal data stated in this form may be submitted to the competent authorities of the Republic of Croatia for the purpose of verification when deciding on this application.

(mjesto i datum / place and date) Prilozi / Annexes:

M.P. L.S.

(podnositelj zahtjeva / applicant)

13958/10