Ԕԝɠɚɬɬɚɪɞɵ ɫɚԕɬɚɭԑɚ
ԕɚɛɵɥɞɚɭ ɬɭɪɚɥɵ ɤɭԥɥiɤ
_______________________________ ԕɚɥɚɫɵ (ɚɭɵɥɵ, ɤɟɧɬi, ԧɥɤɟɫi, ɨɛɥɵɫɵ)
_______________________________________ ԕɚɥɚɫɵ (ɤɟɧɬi, ɚɭɵɥɵ, ɨɛɥɵɫɵ)
__________________________________________________________________
(ɤԛɧi, ɚɣɵ, ɠɵɥɵ)
Ɇɟɧ,___________________________________________,___________________
(ɦɟɦɥɟɤɟɬɬiɤ ɧɨɬɚɪɢɚɬ ɤɟԙɫɟɫiɧiԙ ɚɬɚɭɵ ɧɟɦɟɫɟ ɠɟɤɟɲɟ ɧɨɬɚɪɢɭɫ
__________________________________________________________________
ɥɢɰɟɧɡɢɹɫɵɧɵԙ ɧԧɦiɪi ɦɟɧ ɤԛɧi)
__________________________________________________________________
ɧɨɬɚɪɢɭɫɵ
__________________________________________________________________
(Ɍ.Ⱥ.Ԥ.)
___________________ ɬԝɪɚɬɵɧ ɚɡ. ___________________________________
(ɨɧɵԙ ɬԝɪɚɬɵɧ ɠɟɪi) (Ɍ.Ⱥ.Ԥ.,ɬɭԑɚɧ ɠɵɥɵ, ɬɭԑɚɧ ɠɟɪɿ)
20_____ ɠɵɥɞɵԙ "______"____________ _______ _______________________
(ɦɟɤɟɧ ɠɚɣɵ)
ɦɟɦɥɟɤɟɬɬiɤ ɧɨɬɚɪɢɚɬ ɤɟԙɫɟɫiɧɟ (ɧɟɦɟɫɟ ɠɟɤɟɲɟ ɧɨɬɚɪɢɭɫԕɚ)__________
_________________ ɦɟɪɡiɦɝɟ ԕɨɫɚ ɛɟɪiɥiɩ ɨɬɵɪԑɚɧ ɬiɡiɦɞɟɦɟɝɟ ɫԥɣɤɟɫ
(ɦɟɪɡiɦi ɫԧɡɛɟɧ ɤԧɪɫɟɬiɥɟɞi) ԕԝɠɚɬɬɚɪɞɵ ɦɚԑɚɧ ɫɚԕɬɚɭԑɚ ɬɚɩɫɵɪԑɚɧɵɧ
ɤɭԥɥɚɧɞɵɪɚɦɵɧ.
Ԕԝɠɚɬɬɚɪɞɵ ɫɚԕɬɚɭԑɚ ɬɚɩɫɵɪԑɚɧ ɚɞɚɦɧɵԙ ɠɟɤɟ ɛɚɫɵ ɚɧɵԕɬɚɥɞɵ, ԥɪɟɤɟɬ
ԕɚɛɿɥɟɬɬɿɥɿɝɿ ɬɟɤɫɟɪɿɥɞɿ.
ʋ _______ɬiɡiɥiɦɞɟ ɬiɪɤɟɥɞi
Ɇɟɦɥɟɤɟɬɬiɤ ɛɚɠ ԧɧɞiɪiɥɞi
ɧɟɦɟɫɟ ɠɟɤɟɲɟ ɧɨɬɚɪɢɭɫԕɚ
ɬԧɥɟɧɝɟɧ ɫɨɦɚ ________
187
ɦԧɪ ɇɨɬɚɪɢɭɫ ____________
Ԧɬiɧiɲ ɛɟɪɭ ɬɭɪɚɥɵ ɤɭԥɥiɤ
_______________________________________ ԕɚɥɚɫɵ (ɤɟɧɬi, ɚɭɵɥɵ, ɨɛɥɵɫɵ)
__________________________________________________________________
(ɤԛɧi, ɚɣɵ, ɠɵɥɵ)
Ɇɟɧ,___________________________________________,___________________
(ɦɟɦɥɟɤɟɬɬiɤ ɧɨɬɚɪɢɚɬ ɤɟԙɫɟɫiɧiԙ ɚɬɚɭɵ ɧɟɦɟɫɟ ɠɟɤɟɲɟ ɧɨɬɚɪɢɭɫ
__________________________________________________________________
ɥɢɰɟɧɡɢɹɫɵɧɵԙ ɧԧɦiɪi ɦɟɧ ɤԛɧi)
__________________________________________________________________
ɧɨɬɚɪɢɭɫɵ
__________________________________________________________________
(Ɍ.Ⱥ.Ԥ.)
"ɇɨɬɚɪɢɚɬ ɬɭɪɚɥɵ" ԔɊ Ɂɚԙɧɵԙ 84-ɛɚɛɵɧɵԙ ɧɟɝiɡiɧɞɟ ɦɟɧ ɚɪԕɵɥɵ________
ɠɵɥɞɵԙ
"____"______________________________________________________
(Ɍ.Ⱥ.Ԥ.ɬɭԑɚɧ ɠɵɥɵ, ɬɭԑɚɧ ɠɟɪɿ ɧɟɦɟɫɟ ԧɬɿɧɿɲ ɛɟɪɝɟɧ _____________ ɛɟɪɝɟɧiɧ
ɤɭԥɥɚɧɞɵɪɚɦɵɧ.
ԝɣɵɦɧɵԙ ɚɬɚɭɵ)
Ԧɬiɧiɲ ɦɚɡɦԝɧɵ
ɦɵɧɚɞɚɣ___________________________________________________________
__________________________________________________________________
(ԧɬiɧiɲɬiԙ ԕɵɫԕɚɲɚ ɦɚɡɦԝɧɵ ɤԧɪɫɟɬiɥɟɞi)
Ԧɬiɧiɲ ɛɟɪɝɟɧ ɚɡɚɦɚɬɬɵԙ (ԧɤiɥɞiԙ) ɠɟɤɟ ɛɚɫɵ ɚɧɵԕɬɚɥɞɵ, ԥɪɟɤɟɬ ԕɚɛɿɥɟɬɬɿɥɿɝɿ
ɬɟɤɫɟɪɿɥɞɿ.
ʋ _______ɬiɡiɥiɦɞɟ ɬiɪɤɟɥɞi
Ɇɟɦɥɟɤɟɬɬiɤ ɛɚɠ ԧɧɞiɪiɥɞi
ɧɟɦɟɫɟ ɠɟɤɟɲɟ ɧɨɬɚɪɢɭɫԕɚ
ɬԧɥɟɧɝɟɧ ɫɨɦɚ ________
ɦԧɪ ɇɨɬɚɪɢɭɫ ________ (ԕɨɥɵ)
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