ɏȺɇȺɇȾ ɋȺɅɏɂȼɑ, ɍɌȺȺɇɕ ɋɍȼȺȽ ɏɂɃɋɗɇ ȺɄɌ

20........ɨɧɵ ....... ɫɚɪɵɧ .......... ԧɞԧɪ

.............................................................ɚɣɦɚɝ, ɯɨɬɵɧ ..........................................................-ɧɞ
/ɞίίɪɷɝ, ɫɭɦ, ɛɪɢɝɚɞ/
ɛɚɪɢɝɞɚɠ ɛɚɣɝɚɚ ........................................................................................ ɛɚɪɢɥɝɵɧ ɯɚɧɚɧɞ
......................................................... ɫɭɜɝɢɣɝ ɚɠɥɵɧ ɡɭɪɝɢɣɧ ...............................-ɪ ɯɭɭɞɫɚɧɞ
(ɸɭɧɵ)
ɡɚɚɝɞɫɚɧɵ ɞɚɝɭɭ ɯɢɣɝɞɫɷɧ ɷɫɷɯɢɣɝ ɡɚɯɢɚɥɚɝɱɢɣɧ ɬԧɥԧԧɥԧɝɱ …………………..……………..

ɛɚɪɢɥɝɵɧ ɢɧɠɟɧɟɪ………………………………… ɞɚɚɦɚɥ ………………………………………

ɛɢɞ ɲɚɥɝɚɯɚɞ :

1. Ȼɚɪɢɥɝɵɧ ............................................... ɛɥɨɤ, ɯɷɫɷɝ ............................................-ɪ

ɞɚɜɯɪɵɧ .......................................................................................................ɬɷɧɯɥɷɝԛԛɞ ɞɷɷɪɯ
ɯɚɧɚɧɞ ɚɠɥɵɧ ɡɭɪɝɚɚɪ ............................................................................................................
(ɹɦɚɪ ɯɷɦɠɷɷɬɷɣ, ɯɷɞɷɧ ɲɢɪɯɷɝ)

ɫɭɜɚɝ ɝɚɪɝɚɯɵɝ …………………………………………………………………………………………

(ɯɚɚɧɚ, ɚɥɶ ɬɷɧɯɥɷɝɬ, ɹɦɚɪ ɯɷɦɠɷɷɬɷɣ

……………………………………………………………………………………………………………
ɏɷɞɷɧ ɲɢɪɯɷɝ, ɸɭɧɵ ɫɭɜɚɝ)
ɫɭɜɚɝ ɝɚɪɝɚɫɚɧ ɛɚɣɧɚ.

2. Ƚɚɪɝɚɫɚɧ ɫɭɜɚɝ ɧɶ .....................................................................................................

(ɲɚɜɚɪɞɫɚɧ, ɧίɯ ɫίɜɬɷɣ ɷɫɷɯ)

…………………………………………………………………………………………………..ɚɪɝɚɚɪ
ɲɚɥɝɚɠ ԛɡɫɷɧ.

3. …………………………………………………………………………….………………….
(ɫɚɥɯɢɜɱ, ɭɬɚɚɧɵ ɫɭɜɚɝ, ɬλɦλɪ ɛɟɬɨɧ ɛίɫɢɣɝ ɧɷɜɬɥɷɧ

……………………………………………………………………………………………………………Ƚ
ɚɪɚɯ ɯɷɫɷɝɬ ɹɚɠ ɝɚɪɝɚɫɧɵɝ ɬɨɞɨɪɯɨɣɥɨɧ ɛɢɱɧɷ)

4...................................................... ɫɭɜɚɝ ........................ɱɚɧɚɪɬɚɣ ɛɨɥɫɨɧ ɝɷɠ ԛɡɷɜ.

Ɂɚɯɢɚɥɚɝɱɢɣɧ ɬԧɥԧԧɥԧɝɱ : .............................................................................

Ȼɚɪɢɥɝɵɧ ɢɧɠɟɧɟɪ : ......................................................................................

Ⱦɚɚɦɚɥ : ........................................................................................................

40