รวมระเบียบ คำสั่ง เกี่ยวกับการจดทะเบียนสิทธิและนิติกรรมประเภท ก่อภาระผูกพัน และอื่น ๆ (ปี 2552)

˘˜

μ—«Õ¬“à ßÀ¡“¬‡≈¢ Ú (∑.¥. Ò)

∑∫’Ë “â π

(‚©π¥∑Ë’‡ªπì ¿“√¬∑√æ— ¬å) ∑Ë’ «π/‰√à

∑’Ëπ“

∑.’Ë .............

’Ë∑¥‘π‚©π¥∑Ë’ ÒÛı Õ”‡¿Õ...................®—ßÀ«—¥...............‡©æ“– à«π¢Õß π“¬ °. μ°Õ¬Ÿà„π∫—ߧ—∫¿“√–®”¬Õ¡‡√Ë◊Õß∑“߇¥‘π ∑“ß√∂¬πμå ‰øøÑ“ ª√–ª“ μ≈Õ¥®π §”¢Õ®¥∑–‡∫¬’ π ‘∑∏·‘ ≈–π‘μ‘°√√¡ πÕ°‡¢μ
 “∏“√≥Ÿª‚¿§μà“ßÊ ¢Õß∑Ë’ ‘¥π‚©π¥∑Ë’ ÒÛıÛ Õ”‡¿Õ............... —®ßÀ«—¥...............μ“¡∫—π∑÷°¢âÕμ°≈ß ©∫—∫≈ß«—π∑’Ë..........‡ ◊¥Õπ.......................æ.»............... ·≈–°“√ Õ∫ «π ‘∑∏‘„π∑¥Ë’ ‘π ª√–‡¿∑...¿...“..√..–..®..”..¬..Õ..¡...‡.©..æ...“..–.. ..à«..π......... „π‡¢μ

‡®â“æπ—°ß“π Ë’∑¥‘π μ”·Àπàß∑’Ë¥‘π

√–«“ß......................................................................................... μ”∫≈.........................................................................................

‡≈¢∑’Ë¥‘π..................................................................................... Õ”‡¿Õ........................................................................................

Àπ“â  ”√«®..................................................................................®—ßÀ«¥— ........................................................................................

‚©π¥∑Ë¥’ π‘ ÒÛı
‡≈¢∑.Ë’ .....................Ò...Û..ı..Û...............‡≈à¡........................................Àπâ“....................................

®”π«π∑¥’Ë ‘π...................................‰√à.................................ß“π...................................μ“√“ß«“

Ò. ¢â“懮“â º¡âŸ π’ “¡μàÕ‰ªπÈ’ ¡’§«“¡ª√– ß§å¢Õ®¥∑–‡∫¬’ π ∑‘ ∏‘·≈–π‘μ‘°√√¡‡°’ˬ«°∫— Õ ß— À“√¡‘ ∑√æ— ¬∑å ’°Ë ≈“à «¢â“ß∫ππ’È ·≈–

‰¥âªØ‘≠“≥μπ·≈«â ¢Õ„Àâ∂âÕ¬§”¥«â ¬§«“¡ μ— ¬å®√ß‘ ∂â“¢“â 懮“â „Àâ∂âÕ¬§”‰¡à‡ªì𧫓¡®√‘ß„Àâ„™∂â âÕ¬§”π’¬È π— ¢“â 懮“â „π∑“ߧ¥Õ’ “≠“‰¥â

Ú. ¢“â 懮â“....π..“..¬...°......‡.®..â“..¢..Õ...ß..¿..“..√..¬..∑..√..æ—...¬..å.... ‡≈¢ª√–®”μ—«ª√–™“™π º.⟠..¢..Õ.................................

.................................................

Õ“¬.ÿ .................................ªï  ≠— ™“μ‘.........................................∫¥‘ “/¡“√¥“™Ë◊Õ.............................................................................

‚ ¥ À¡“â ¬ § àŸ ¡√ ™ËÕ◊ ..........................................................................................

Õ¬àŸ∑Ë’∫“â π/À¡à∫Ÿ “â π..........................‡≈¢∑.’Ë ...............μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡∑àŸ ’.Ë .............

μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«¥— .................................À¡“¬‡≈¢‚∑√»—æ∑.å ....................

Û. ¢“â 懮“â ...π..“..¬....§......‡.®..â“..¢..Õ..ß.. ...“.¡...¬..∑..√..—æ...¬..å.... ‡≈¢ª√–®”μ—«ª√–™“™π º.⟠..¢..Õ.................................

................................................
Õ“¬.ÿ .................................ªï  ≠— ™“μ.‘ ........................................∫¥‘ “/¡“√¥“™ÕË◊ .............................................................................

‚ ¥ À¡“â ¬ §Ÿà ¡√ ™Õ◊Ë ....................................................... ≠— ™“μ‘.......................
Õ¬∑àŸ ’∫Ë â“π/À¡à∫Ÿ “â π..........................‡≈¢∑’Ë................μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡Ÿà∑’Ë..............
μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®—ßÀ«—¥.................................À¡“¬‡≈¢‚∑√»—æ∑.å ....................

Ù. ¢“â 懮“â ¢Õ· ¥ß√“§“∑√æ— ¬∑å ¢’Ë Õ∑”πμ‘ ‘°√√¡πÈ’‡ªìπ‡ßπ‘ .............................›............................∫“∑.........›........... μ“ߧå
ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à

(Ò) ¢â“懮Ⓣ¡à‰¥√â —∫‚Õπ·∑πÀ√◊Õ‡æËÕ◊ ª√–‚¬™π·å °∫à §ÿ §≈μ“à ߥ“â «
(Ú) √“§“∑√—æ¬å∑’Ë· ¥ß‰«â„π Ù. ‡ªπì √“§“∑’·Ë ∑®â √ß‘
(Û) .‰.¡..¡à...§’ ..“à..μ..Õ...∫..·..∑...π...(..¡..’§..“à..μ...Õ..∫..·...∑..π..‡..ª..πì..‡..ß..‘π........................................................∫..“..∑..)............................................................................
(Ù) .π..“..¬....¢..‹..º..∂Ÿâ..Õ◊...°..√..√..¡.. ...‘∑..∏..‘°Ï..∫—....π...“.¬....°....‰..¥..â„..À..§â..«..“..¡...¬..π‘ ..¬..Õ...¡..μ...“.¡...∫..π—..∑...÷°..©..∫...∫— ..≈..ß..«..—π...∑..Ë’......‡.¥..Õ◊...π..................æ....».......................
(ı) .....................................................................................................................................................................

«π— ∑.’Ë ...........‡¥Õ◊ π..............................æ.»..................
≈ß™Ë◊Õ.....................π..“..¬...°...........................ºŸâ¢Õ ‡®â“¢Õß¿“√¬∑√—æ¬å
≈ß™ËÕ◊ .....................π..“..¬...§..........................ºŸâ¢Õ ‡®“â ¢Õß “¡¬∑√æ— ¬å
≈ß™Õ◊Ë ......................................................º Ÿâ Õ∫ «π

(......................................................)
 ”À√—∫æπ—°ß“π‡®“â Àπâ“∑’Ë
Ò) √“§“ª√–‡¡π‘ ∑ÿπ∑√æ— ¬.å ....................................................................................................∫“∑........................................ μ“ߧå
Ú) ‚©π¥∑¥’Ë π‘ „À¡√à –«“ß............................................‡≈¢∑¥Ë’ π‘ ...............................................Àπ“â  ”√«®.........................................
‚©π¥∑’Ë¥‘π‡≈¢∑.’Ë ..................................................‡≈¡à ......................................................Àπâ“..................................................
®”π«π∑¥Ë’ π‘ ......................................................‰√.à ................................................ß“π..................................................μ“√“ß«“
§ß‡À≈Õ◊ ...........................................................‰√.à ................................................ß“π..................................................μ“√“ß«“
Û) ‰¥â®¥∑–‡∫’¬π·≈â«·μà«π— ∑Ë’.................................‡¥◊Õπ............................................æ.»......................

≈ß™ËÕ◊ .......................................................
(......................................................)
‡®â“æπ—°ß“π∑’Ë¥‘π

˘¯

μ—«Õ¬à“ßÀ¡“¬‡≈¢ Ú (∑.¥. Òˆ)
(‚©π¥∑’ˇªπì ¿“√¬∑√—æ¬å)

∫π— ∑°÷ ¢âÕμ°≈߇√ÕË◊ ß¿“√–®”¬Õ¡‡©æ“– à«π

∑’Ë¥‘π
√–«“ß...............................................................................μ”∫≈........................................................................
‡≈¢∑Ë¥’ ‘π...............................Àπâ“ ”√«®............................Õ”‡¿Õ.......................................................................
‚©π¥À¡“¬‡≈¢∑Ë.’ ..............................................................®—ßÀ«¥— .......................................................................
∑’Ë«“à °“√.....................................................................

«π— ∑.’Ë ...............‡¥◊Õπ........................................æ.».....................

¢“â 懮“â .....................π..“..¬....°.......‡.®..“â..¢..Õ..ß..¿...“..√..¬..∑..√..—æ...¬..å .................................. ‡≈¢ª√–®”μ—«ª√–™“™π

.....................π..“..¬....§.......‡.®..“â..¢..Õ...ß.. ..“..¡..¬..∑...√..æ— ..¬..å..................................

Õ“¬ÿ...................ªï ‡™ÕÈ◊ ™“μ‘............................... ≠— ™“μ.‘ ..............................∫¥‘ “/¡“√¥“™ÕË◊ ............................................................

Õ¬∑Ÿà Ë’∫â“π/À¡àŸ∫“â π......................................‡≈¢∑.Ë’ .............μ√Õ°/´Õ¬.....................................∂ππ.................................À¡Ÿà∑Ë.’ .........

μ”∫≈/·¢«ß...............................Õ”‡¿Õ/‡¢μ...............................®ß— À«—¥................................À¡“¬‡≈¢‚∑√»æ— ∑.å .............................

¢//Õ//ª//Ø//≠‘ //“/≥///μ//π//·/≈//–//„/À//∂â //Õâ //¬/§//”//μ/àÕ//......‰.¥..â∑...”..∫..π—..∑...÷°..¢..âÕ..μ...°..≈..ß..μ...Õà ..‡.®..â“..æ...π..°—..ß..“..π..∑...’¥Ë ..π‘.....................................................................................

¥//â«//¬//§//«/“/¡// //μ—//¬//®å /√//‘ß/ ¥ß— μÕà ‰ªπ’È :›
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.ª..√..–..‚..¬..™..π...å®..“..°..¿...“..√..–..®..”..¬...Õ..¡...¥..ß—..°...≈..à“..«..·...≈..«â....ª..√..“..°...Ø..μ...“..¡..√..ªŸ...·..º...π..∑...’Ë ..ß—..‡..¢..ª..μ...Õà..∑...“â ..¬..¢...âÕ..μ..°...≈..ß..π...’È........................................................................
......................¢..Õâ....Ú.......°...“..√..¢..Õ...®..¥..∑...–..‡.∫...’¬..π...¿..“..√..–...®..”..¬..Õ...¡..¥...ß— ..°..≈...“à ..«..‰.¡..à¡...’§...“à .μ...Õ..∫...·..∑...π....(.¡...’§..“à..μ...Õ..∫...·..∑...π..‡.ª...πì..‡..ß..‘π......................................∫...“..∑..)..........................
......................¢..âÕ....Û.......¢...Õ..‡.®...â“..æ..π...—°..ß..“..π...∑..Ë’¥...‘π..‰..¥..â‚..ª..√..¥...®..¥...∑..–..‡..∫..’¬...π..¿...“.√...–..®..”..¬..Õ...¡..‡..©..æ...“..–.. ..à«..π...„.À...μâ ..“..¡...§..«..“..¡...ª..√..–... ..ß..§...¢å ..Õ..ß...¢..â“..æ...‡.®..â“..¥...«â ..¬....¢..“â ..æ..‡..®..“â..
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.≈..ß..«..—π...∑...’Ë.................‡.¥...◊Õ..π...............................................æ.....»..........................¡...“..·.. ..¥...ß..¥...«â ..¬..·..≈...«â ......................................................................................................................
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............................................................................................≈..ß...™..◊ËÕ...........................................................π......“....¬.........°.......................................................‡.®..“â..¢...Õ..ß..¿...“..√..¬..∑...√..—æ...¬..å ...................
............................................................................................≈..ß...™..Ë◊Õ...........................................................π......“....¬.........§......................................................‡.®..“â..¢...Õ..ß.. ...“..¡..¬...∑..√..æ—...¬..å...................
............................................................................................≈..ß...™..◊ËÕ....................................................................................................................................æ...¬..“..π...........................................
............................................................................................≈..ß...™..◊ËÕ.....................................................................................................................................æ...¬..“..π...........................................
.............................∫...—π..∑...÷°..¢...Õâ ..μ...°..≈..ß..π...È’‰..¥..∑â...”..μ..Õà...À..π...“â ......................................................................................................................................
............................................................................................≈..ß...™..Ë◊Õ.....................................................................................................................................‡.®..“â..æ...π...°— ..ß..“..π..∑...¥’Ë..π‘..........................
..........................................................................................................ª..√..–..∑...∫—..μ...√..“..μ...”.·...À..π...ßà ..‡.ª...πì.. ...”..§..≠—..........................................................

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˘˘

μ—«Õ¬“à ßÀ¡“¬‡≈¢ Ú

·ºπ∑∑’Ë “â ¬∫π— ∑÷°¢Õâ μ°≈߇√◊ËÕß¿“√–®”¬Õ¡‡©æ“– «à π
‚©π¥‡≈¢∑’Ë ÒÛı ‡≈¢∑¥Ë’ π‘ ..............Àπ“â  ”√«®.............

N

μ”∫≈..................Õ”‡¿Õ..................®ß— À«—¥....................
▼

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///////////////// ‡¢μ∑¥’Ë ‘π ‚©‹π¥∑Ë’ ÒÛı ‡π◊ÕÈ ∑’Ë...................‰√à
‡¢μ ·’ ¥ß ‡ªìπ‡¢μ∑Ë®’ ¥∑–‡∫¬’ π¿“√–®”¬Õ¡‡©æ“– «à π
°«â“ߪ√–¡“≥........................¬“«ª√–¡“≥..................
√«¡‡πÈÕ◊ ∑’˪√–¡“≥.................‰√à

≈ß™Õ◊Ë .......................π..“..¬....°.......................‡®“â ¢Õß¿“√¬∑√æ— ¬å
≈ß™ÕË◊ .......................π..“..¬....§........................‡®“â ¢Õß “¡¬∑√—æ¬å
≈ß™ÕË◊ ......................................................欓π
≈ß™Õ◊Ë ......................................................欓π
≈ß™Õ◊Ë ......................................................‡®“â æπ°— ß“π∑’Ë¥‘π

μ—«Õ¬à“ßÀ¡“¬‡≈¢ Ú Ò

 “√∫≠— ®¥∑–‡∫’¬π

(‚©π¥∑‡Ë’ ªìπ¿“√¬∑√—æ¬)å

®¥∑–‡∫’¬π ª√–‡¿∑°“√ ºŸâ„À â ≠— ≠“ ºâŸ√—∫ —≠≠“ ‡π◊ÈÕ∑’Ë¥‘π ‡πÈ◊Õ∑’Ë¥‘π √–«“ß ‡®â“æπ—°ß“π∑Ë’¥‘π
«—𠇥Õ◊ π ªï ®¥∑–‡∫’¬π μ“¡ ≠— ≠“ §ß‡À≈Õ◊ ‡≈¢∑Ë’¥‘π ≈ß≈“¬¡Õ◊ ™Õ◊Ë
‚©π¥∑¥Ë’ π‘ „À¡à ª√–∑∫— μ√“
«—π∑’Ë..................... ¿“√–®”¬Õ¡ ‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
‡¥◊Õπ................... ‡©æ“– «à π «“ «“
æ.». .....................
∑¥’Ë ‘π·ª≈ßπÈ’‡©æ“– «à π¢Õß π“¬ °. μ°Õ¬Ÿà„π∫—ߧ∫— ¿“√–®”¬Õ¡‡√Õ◊Ë ß∑“߇¥π‘ (≈ß™◊ËÕ).........................
∑“ß√∂¬πμå ‰øø“Ñ ª√–ª“ μ≈Õ¥®π “∏“√≥Ÿª‚¿§μ“à ßÊ ¢Õß∑Ë¥’ ‘π‚©π¥∑’Ë ÒÛıÛ
Õ”‡¿Õ.........®ß— À«—¥..............μ“¡∫π— ∑°÷ ¢âÕμ°≈ß©∫—∫≈ß«—π∑.’Ë .......‡¥◊Õπ..............æ.». .....

ÒÒ

μ—«Õ¬à“ßÀ¡“¬‡≈¢ Û (∑.¥. Ò)

∑∫Ë’ “â π

(‚©π¥∑‡Ë’ ªπì ¿“√¬∑√—æ¬)å ∑ ’Ë «π/‰√à

∑Ë’π“

∑’.Ë .............

§”¢Õ®¥∑–‡∫’¬π ∑‘ ∏·‘ ≈–π‘μ‘°√√¡ πÕ°‡¢μ
·≈–°“√ Õ∫ «π ‘∑∏‘„π∑Ë¥’ ‘π ª√–‡¿∑...¿...“..√..–..®..”..¬..Õ..¡...∫..“..ß.. ..à«..π............. „π‡¢μ

’Ë∑¥‘π∫“ß à«π¢Õß‚©π¥∑’Ë ÒÛı Õ”‡¿Õ...................®—ßÀ«—¥...............μ°Õ¬àŸ„π∫—ߧ—∫¿“√–®”¬Õ¡‡√Ë◊Õß∑“߇¥‘π ∑“ß√∂¬πμå ‰øøÑ“ ª√–ª“ μ≈Õ¥®π μ”·Àπàß∑’Ë¥‘π
 “∏“√≥Ÿª‚¿§μà“ßÊ ¢Õß∑Ë’ ‘¥π‚©π¥∑Ë’ ÒÛıÛ Õ”‡¿Õ.................. —®ßÀ«—¥..................μ“¡∫—π∑÷° â¢Õμ°≈ß ©∫—∫≈ß«—π∑’Ë..........‡ ◊¥Õπ.......................æ.»...............
√–«“ß.........................................................................................μ”∫≈.........................................................................................
‡®â“æπ—°ß“π Ë’∑¥‘π
‡≈¢∑’¥Ë ‘π.....................................................................................Õ”‡¿Õ........................................................................................

Àπ“â  ”√«®..................................................................................®ß— À«¥— ........................................................................................

‚©π¥∑¥Ë’ π‘ ÒÛı
‡≈¢∑.Ë’ .....................Ò...Û..ı..Û...............‡≈¡à ........................................Àπ“â ....................................

®”π«π∑’¥Ë ‘π...................................‰√à.................................ß“π...................................μ“√“ß«“

Ò. ¢â“懮“⠺⡟ π’ “¡μàÕ‰ªπÈ’ ¡§’ «“¡ª√– ß§¢å Õ®¥∑–‡∫¬’ π ∑‘ ∏·‘ ≈–πμ‘ °‘ √√¡‡°’ˬ«°—∫Õ —ßÀ“√¡‘ ∑√—æ¬∑å ’°Ë ≈à“«¢“â ß∫ππÈ’ ·≈–

‰¥ªâ Ø‘≠“≥μπ·≈«â ¢Õ„Àâ∂âÕ¬§”¥â«¬§«“¡ —쬮å √‘ß ∂â“¢â“懮ⓄÀâ∂Õâ ¬§”‰¡à‡ªπì §«“¡®√ß‘ „Àâ„™∂â Õâ ¬§”π¬’È —π¢â“懮Ⓞπ∑“ߧ¥Õ’ “≠“‰¥â

Ú. ¢“â 懮“â ....π..“..¬...°......‡.®..â“..¢..Õ..ß...¿..“..√..¬..∑..√..æ—...¬..å.... ‡≈¢ª√–®”μ—«ª√–™“™π º.⟠..¢..Õ.................................

.................................................

Õ“¬.ÿ .................................ªï  —≠™“μ‘.........................................∫¥‘ “/¡“√¥“™◊ÕË .............................................................................

‚ ¥ À¡“â ¬ § Ÿà ¡√ ™◊ÕË ..........................................................................................

Õ¬Ÿ∑à ∫’Ë “â π/À¡Ÿà∫“â π..........................‡≈¢∑Ë.’ ...............μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡∑àŸ ’.Ë .............

μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«—¥.................................À¡“¬‡≈¢‚∑√»—æ∑.å ....................

Û. ¢“â 懮“â ...π..“..¬....¢.....‡..®..“â ..¢..Õ..ß.. ..“..¡...¬..∑..√..æ—...¬..å.... ‡≈¢ª√–®”μ—«ª√–™“™π º.⟠..¢..Õ.................................

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Õ“¬.ÿ .................................ªï  ≠— ™“μ‘.........................................∫‘¥“/¡“√¥“™◊ËÕ.............................................................................

‚ ¥ À¡“â ¬ § Ÿà ¡√ ™ËÕ◊ ....................................................... —≠™“μ.‘ ......................
Õ¬Ÿà∑∫Ë’ “â π/À¡à∫Ÿ â“π..........................‡≈¢∑Ë’................μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡Ÿ∑à Ë.’ .............
μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«—¥.................................À¡“¬‡≈¢‚∑√»æ— ∑.å ....................

Ù. ¢â“懮ⓢշ ¥ß√“§“∑√—æ¬å∑’¢Ë Õ∑”πμ‘ ‘°√√¡πȇ’ ªπì ‡ßπ‘ .............................›............................∫“∑.........›........... μ“ߧå
ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à

(Ò) ¢â“懮“â ‰¡à‰¥√â —∫‚Õπ·∑πÀ√◊Õ‡æËÕ◊ ª√–‚¬™π·å °à∫§ÿ §≈μà“ߥ“â «
(Ú) √“§“∑√æ— ¬∑å ’·Ë  ¥ß‰«â„π Ù. ‡ªπì √“§“∑’·Ë ∑â®√ß‘
(Û) .‰.¡..¡à...’§..“à..μ..Õ...∫..·..∑...π...(..¡..§’..“à..μ...Õ..∫..·...∑..π..‡..ª..ìπ..‡..ß..‘π........................................................∫..“..∑..)............................................................................
(Ù) .....................................................................................................................................................................
(ı) .....................................................................................................................................................................

«π— ∑.’Ë ...........‡¥Õ◊ π..............................æ.»..................
≈ß™ËÕ◊ .....................π..“..¬...°...........................ºâŸ¢Õ ‡®â“¢Õß¿“√¬∑√æ— ¬å
≈ß™◊ËÕ.....................π..“..¬...¢..........................ºâŸ¢Õ ‡®“â ¢Õß “¡¬∑√æ— ¬å
≈ß™◊ÕË ......................................................º âŸ Õ∫ «π

(......................................................)
 ”À√—∫æπ—°ß“π‡®“â Àπâ“∑Ë’
Ò) √“§“ª√–‡¡π‘ ∑ÿπ∑√æ— ¬.å ....................................................................................................∫“∑........................................ μ“ߧå
Ú) ‚©π¥∑¥Ë’ π‘ „À¡à√–«“ß............................................‡≈¢∑¥’Ë ‘π...............................................Àπ“â  ”√«®.........................................
‚©π¥∑Ë¥’ π‘ ‡≈¢∑.Ë’ ..................................................‡≈¡à ......................................................Àπ“â ..................................................
®”π«π∑¥Ë’ π‘ ......................................................‰√.à ................................................ß“π..................................................μ“√“ß«“
§ß‡À≈Õ◊ ...........................................................‰√.à ................................................ß“π..................................................μ“√“ß«“
Û) ‰¥®â ¥∑–‡∫’¬π·≈«â ·μà«π— ∑’Ë.................................‡¥Õ◊ π............................................æ.»......................

≈ß™ÕË◊ .......................................................
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‡®â“æπ—°ß“π∑’Ë¥‘π

ÒÚ

μ«— Õ¬à“ßÀ¡“¬‡≈¢ Û (∑.¥. Òˆ)
(‚©π¥∑’ˇªìπ¿“√¬∑√æ— ¬å)

∫π— ∑°÷ ¢Õâ μ°≈߇√◊ËÕß¿“√–®”¬Õ¡∫“ß à«π

∑’Ë¥‘π

√–«“ß...............................................................................μ”∫≈........................................................................

‡≈¢∑’¥Ë ‘π...............................Àπâ“ ”√«®............................Õ”‡¿Õ.......................................................................
‚©π¥À¡“¬‡≈¢∑Ë.’ ..................ÒÒ..ÛÛ..ıı..Û......................................®ß— À«—¥.......................................................................

∑«Ë’ “à °“√.....................................................................

«π— ∑.’Ë ...............‡¥◊Õπ........................................æ.».....................

¢“â 懮“â .....................π..“..¬....°.......‡.®..â“..¢..Õ..ß..¿...“..√..¬..∑..√..—æ...¬..å .................................. ‡≈¢ª√–®”μ—«ª√–™“™π

.....................π..“..¬....¢.......‡.®..â“..¢..Õ..ß.. ...“..¡..¬..∑..√..æ—...¬..å..................................

Õ“¬.ÿ ..................ªï ‡™ÈÕ◊ ™“μ.‘ .............................. ≠— ™“μ‘...............................∫¥‘ “/¡“√¥“™Ë◊Õ............................................................

Õ¬àŸ∑∫’Ë â“π/À¡àŸ∫“â π......................................‡≈¢∑Ë.’ .............μ√Õ°/´Õ¬.....................................∂ππ.................................À¡àŸ∑’.Ë .........

μ”∫≈/·¢«ß...............................Õ”‡¿Õ/‡¢μ...............................®ß— À«—¥................................À¡“¬‡≈¢‚∑√»æ— ∑.å .............................
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¥//â«//¬//§//«/“/¡// //μ—//¬//å®/√//ß‘ / ¥ß— μàÕ‰ªπÈ’ :›
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............................................................................................≈..ß...™..◊ËÕ...........................................................π......“....¬.........°.......................................................‡.®..â“..¢...Õ..ß..¿...“..√..¬..∑...√..æ— ...¬..å ...................
............................................................................................≈..ß...™..Ë◊Õ...........................................................π......“....¬.........¢......................................................‡.®..“â..¢...Õ..ß.. ...“..¡..¬...∑..√..æ—...¬..å...................
............................................................................................≈..ß...™..Ë◊Õ....................................................................................................................................æ...¬..“..π...........................................
............................................................................................≈..ß...™..Ë◊Õ.....................................................................................................................................æ...¬..“..π...........................................
.............................∫...—π..∑...÷°..¢...Õâ ..μ...°..≈..ß..π...’ȉ..¥..∑â...”..μ..Õà...À..π...“â ......................................................................................................................................
............................................................................................≈..ß...™..Ë◊Õ.....................................................................................................................................‡.®..“â..æ...π...°— ..ß..“..π..∑...¥’Ë..π‘..........................
..........................................................................................................ª..√..–..∑...∫— ..μ...√..“..μ...”.·...À..π...àß..‡.ª...ìπ.. ...”..§..≠—..........................................................

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ÒÛ

μ«— Õ¬à“ßÀ¡“¬‡≈¢ Û

·ºπ∑∑Ë’ “â ¬∫π— ∑°÷ ¢âÕμ°≈߇√◊ËÕß¿“√–®”¬Õ¡∫“ß à«π
‚©π¥‡≈¢∑Ë’ ÒÛı ‡≈¢∑¥’Ë ‘π..............Àπ“â  ”√«®..............

N

μ”∫≈..................Õ”‡¿Õ...................®—ßÀ«¥— ....................
▼

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///////////////// ‡¢μ∑¥Ë’ ‘π ‚©‹π¥∑’Ë ÒÛı ‡πÕÈ◊ ∑’Ë...................‰√à
‡¢μ ·’ ¥ß ‡ªìπ‡¢μ∑’®Ë ¥∑–‡∫’¬π¿“√–®”¬Õ¡∫“ß à«π
°«“â ߪ√–¡“≥........................¬“«ª√–¡“≥..................
√«¡‡π◊ÈÕ∑Ë’ª√–¡“≥.................‰√à

≈ß™Õ◊Ë .......................π..“..¬....°.......................‡®â“¢Õß¿“√¬∑√—æ¬å
≈ß™Õ◊Ë .......................π..“..¬....¢........................‡®“â ¢Õß “¡¬∑√—æ¬å
≈ß™Õ◊Ë ......................................................欓π
≈ß™Õ◊Ë ......................................................欓π
≈ß™ÕË◊ ......................................................‡®“â æπ°— ß“π∑¥Ë’ π‘

μ—«Õ¬à“ßÀ¡“¬‡≈¢ Û ÒÙ

 “√∫≠— ®¥∑–‡∫¬’ π

(‚©π¥∑ˇ’ ªìπ¿“√¬∑√—æ¬)å

®¥∑–‡∫¬’ π ª√–‡¿∑°“√ ºâŸ„À â ≠— ≠“ ºŸâ√—∫ —≠≠“ ‡πÈ◊Õ∑’Ë¥‘π ‡πÈ◊Õ∑’Ë¥‘π √–«“ß ‡®â“æπ—°ß“π∑Ë’¥‘π
«π— ‡¥Õ◊ π ªï ®¥∑–‡∫¬’ π μ“¡ —≠≠“ §ß‡À≈Õ◊ ‡≈¢∑’Ë¥‘π ≈ß≈“¬¡Õ◊ ™Õ◊Ë
‚©π¥∑’Ë¥π‘ „À¡à ª√–∑∫— μ√“
«—π∑Ë.’ .................... ¿“√–®”¬Õ¡ ‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
‡¥Õ◊ π................... ∫“ß à«π «“ «“
æ.». .....................
∑Ë’¥‘π·ª≈ßπ’È∫“ß à«πμ°Õ¬àŸ„π∫—ߧ—∫¿“√–®”¬Õ¡‡√◊ÕË ß∑“߇¥‘π ∑“ß√∂¬πμå ‰øøÑ“ (≈ß™◊ËÕ).........................
ª√–ª“ μ≈Õ¥®π “∏“√≥Ÿª‚¿§μ“à ßÊ ¢Õß∑’Ë¥‘π‚©π¥∑’Ë ÒÛıÛ Õ”‡¿Õ......................
®—ßÀ«—¥.........................μ“¡∫—π∑°÷ ¢Õâ μ°≈ß©∫∫— ≈ß«—π∑Ë’........‡¥◊Õπ......................æ.». ........

Òı

μ«— Õ¬à“ßÀ¡“¬‡≈¢ Ù (∑.¥. Ò)

∑∫Ë’ “â π

(‚©π¥∑‡’Ë ªìπ¿“√¬∑√æ— ¬å) ∑ Ë’ «π/‰√à

∑’Ëπ“

∑.’Ë .............

Ë∑’¥‘π‚©π¥∑Ë’ ÒÛı Õ”‡¿Õ................... —®ßÀ«—¥...............∫“ß à«πμ°‡ªìπ¿“√–®”¬Õ¡‡√Ë◊Õß∑“߇¥‘π ∑“ß√∂¬πμå ‰øøÑ“ ª√–ª“ μ≈Õ¥®π “∏“√≥Ÿª‚¿§μà“ßÊ ¢Õß∑’Ë ‘¥π‚©π¥∑’Ë ÒÛıÛ §”¢Õ®¥∑–‡∫’¬π ‘∑∏‘·≈–π‘μ°‘ √√¡ πÕ°‡¢μ
Õ”‡¿Õ................. —®ßÀ —«¥................μ“¡§” Ë—ß»“≈/§” ‘ææ“°…“»“≈..................§ ’¥À¡“¬‡≈¢·¥ß Ë’∑.......≈ß«—π ’Ë∑.......‡ ◊¥Õπ...........æ.»...........·≈–μ“¡§”¢Õ©∫—∫≈ß«—π∑’Ë.......‡¥◊Õπ...........æ.»........... ·≈–°“√ Õ∫ «π ‘∑∏‘„π∑¥’Ë ‘π ª√–‡¿∑...¿...“..√..–..®..”..¬..Õ..¡...∫..“..ß.. ..à«..π............. „π‡¢μ

‡®â“æπ—°ß“π ’Ë∑¥‘π μ”·Àπàß∑’Ë¥‘π (μ“¡§” ß—Ë »“≈/§”æ‘æ“°…“»“≈...............§¥À’ ¡“¬‡≈¢·¥ß∑’Ë........../...........≈ß«—π∑Ë’....................)

√–«“ß......................................................................................... μ”∫≈.........................................................................................

‡≈¢∑’Ë¥‘π..................................................................................... Õ”‡¿Õ........................................................................................

Àπ“â  ”√«®..................................................................................®ß— À«¥— ........................................................................................

‚©π¥∑¥’Ë ‘π ÒÛı
‡≈¢∑’.Ë .....................Ò...Û..ı..Û...............‡≈à¡........................................Àπâ“....................................

®”π«π∑¥Ë’ ‘π...................................‰√.à ................................ß“π...................................μ“√“ß«“

Ò. ¢“â æ‡®â“ºâŸ¡π’ “¡μàÕ‰ªπÈ’ ¡’§«“¡ª√– ß§¢å Õ®¥∑–‡∫¬’ π ∑‘ ∏‘·≈–πμ‘ ‘°√√¡‡°¬’Ë «°∫— Õ ß— À“√‘¡∑√—æ¬∑å °Ë’ ≈à“«¢“â ß∫ππ’È ·≈–

‰¥âªØ‘≠“≥μπ·≈â« ¢Õ„À∂â Õâ ¬§”¥â«¬§«“¡ —μ¬å®√‘ß ∂“â ¢â“懮“â „Àâ∂Õâ ¬§”‰¡à‡ªì𧫓¡®√‘ß„Àâ„™â∂Õâ ¬§”πÈ’¬—π¢â“懮Ⓞπ∑“ߧ¥Õ’ “≠“‰¥â

Ú. ¢â“懮“â ....π..“..¬...°......‡.®..“â..¢..Õ...ß..¿..“..√..¬..∑..√..æ—...¬..å.... ‡≈¢ª√–®”μ—«ª√–™“™π º.⟠..¢..Õ.................................

.................................................

Õ“¬.ÿ .................................ªï  —≠™“μ‘.........................................∫¥‘ “/¡“√¥“™ÕË◊ .............................................................................

‚ ¥ À¡“â ¬ §à Ÿ ¡√ ™◊ËÕ..........................................................................................

Õ¬Ÿà∑’Ë∫â“π/À¡àŸ∫“â π..........................‡≈¢∑’Ë................μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡à∑Ÿ ’.Ë .............

μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«¥— .................................À¡“¬‡≈¢‚∑√»—æ∑å.....................

Û. ¢“â 懮â“...π..“..¬....¢.....‡..®..â“..¢..Õ..ß.. ..“..¡...¬..∑..√..—æ...¬..å.... ‡≈¢ª√–®”μ—«ª√–™“™π º.Ÿâ ..¢..Õ.................................

................................................
Õ“¬.ÿ .................................ªï  —≠™“μ.‘ ........................................∫¥‘ “/¡“√¥“™◊ÕË .............................................................................

‚ ¥ À¡“â ¬ §Ÿà ¡√ ™◊ËÕ....................................................... —≠™“μ‘.......................
Õ¬∑Ÿà Ë’∫“â π/À¡àŸ∫â“π..........................‡≈¢∑’Ë................μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡Ÿà∑.Ë’ .............
μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«¥— .................................À¡“¬‡≈¢‚∑√»æ— ∑å.....................

Ù. ¢“â 懮ⓢշ ¥ß√“§“∑√æ— ¬∑å ’¢Ë Õ∑”π‘μ‘°√√¡π’ȇªπì ‡ßπ‘ .............................›............................∫“∑.........›........... μ“ߧå
ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à

(Ò) ¢â“懮“â ‰¡à‰¥√â —∫‚Õπ·∑πÀ√Õ◊ ‡æ◊ËÕª√–‚¬™π·å °à∫ÿ§§≈μ“à ߥ“â «
(Ú) √“§“∑√—æ¬å∑’·Ë  ¥ß‰«â„π Ù. ‡ªπì √“§“∑Ë’·∑®â √‘ß
(Û) .‰.¡..à¡...’§..“à..μ..Õ...∫..·..∑...π...(..¡..’§..“à..μ...Õ..∫..·...∑..π..‡..ª..πì..‡..ß..‘π........................................................∫..“..∑..)............................................................................
(Ù) .....................................................................................................................................................................

«π— ∑.’Ë ...........‡¥Õ◊ π..............................æ.»..................

(μ“¡§” ß—Ë »“≈/§”æ‘æ“°…“»“≈...............§¥’À¡“¬‡≈¢·¥ß∑.Ë’ ........./...........≈ß«π— ∑’Ë....................)
≈ß™◊ËÕ.....................π..“..¬...°...........................ºŸâ¢Õ ‡®“â ¢Õß¿“√¬∑√—æ¬å
≈ß™Ë◊Õ.....................π..“..¬...¢..........................ºâŸ¢Õ ‡®“â ¢Õß “¡¬∑√æ— ¬å
≈ß™◊ÕË ......................................................º Ÿâ Õ∫ «π
(......................................................)

 ”À√∫— æπ—°ß“π‡®â“Àπ“â ∑Ë’
Ò) √“§“ª√–‡¡π‘ ∑πÿ ∑√—æ¬.å ....................................................................................................∫“∑........................................ μ“ߧå
Ú) ‚©π¥∑Ë¥’ π‘ „À¡à√–«“ß............................................‡≈¢∑¥Ë’ π‘ ...............................................Àπâ“ ”√«®.........................................

‚©π¥∑¥Ë’ ‘π‡≈¢∑Ë.’ ..................................................‡≈¡à ......................................................Àπâ“..................................................
®”π«π∑¥’Ë π‘ ......................................................‰√.à ................................................ß“π..................................................μ“√“ß«“
§ß‡À≈Õ◊ ...........................................................‰√.à ................................................ß“π..................................................μ“√“ß«“
Û) ‰¥â®¥∑–‡∫¬’ π·≈â«·μ«à —π∑Ë’.................................‡¥Õ◊ π............................................æ.»......................

≈ß™◊ËÕ.......................................................
(......................................................)
‡®â“æπ—°ß“π∑’Ë¥‘π

Òˆ

μ—«Õ¬“à ßÀ¡“¬‡≈¢ Ù (∑.¥. ˘)
(‚©π¥∑’ˇªìπ¿“√¬∑√æ— ¬)å

§”¢Õ..®..¥...∑..–..‡..∫..’¬..π...¿..“..√..–..®..”..¬..Õ..¡...∫..“..ß.. ..à«..π............

(μ“¡§” —Ëß»“≈/§”æ‘æ“°…“»“≈...............§¥À’ ¡“¬‡≈¢·¥ß∑.’Ë ........./...........≈ß«π— ∑’.Ë ...................)

©∫—∫∑.Ë’ ......................................

∑Ë’¥‘π

√–«“ß................................................................................μ”∫≈.........................................................................................

‡≈¢∑’Ë.....................................................Àπâ“ ”√«®..................................................Õ”‡¿Õ..................................................

‚©π¥À¡“¬‡≈¢∑’.Ë ......................Ò..Û..ı.....................................®ß— À«—¥.......................................................................................
ÒÛıÛ

«π— ∑Ë’................‡¥Õ◊ π.....................................æ.». ......................

¢â“懮â“...........................π..“..¬....¢................................................................. ‡≈¢ª√–®”μ—«ª√–™“™π

Õ“¬ÿ......Û.........ªï ‡™ÕÈ◊ ™“μ.‘ ..........‰.∑..¬............... —≠™“μ‘..........‰.∑...¬...............∫¥‘ “/¡“√¥“™Ë◊Õ.....................................................................

Õ¬∑Ÿà ∫Ë’ â“π/À¡à∫Ÿ â“π...............................................‡≈¢∑.Ë’ ...................μ√Õ°/´Õ¬............................∂ππ..........................À¡àŸ∑.Ë’ ..........

μ”∫≈/·¢«ß..................................Õ”‡¿Õ/‡¢μ..................................®ß— À«¥— ..................................À¡“¬‡≈¢‚∑√»æ— ∑.å ......................

¢Õ¬◊Ëπ§”¢ÕμÕà ‡®â“æπ°— ß“π∑¥’Ë π‘ ®—ßÀ«—¥....................................................¥â«¬§«“¡ —쬮å √ß‘ «à“ :-
¢Õâ Ò. ¥«â ¬...∑...¥’Ë ..π‘...‚.©..π..¥...∑..’Ë..Ò..Û..ı......Õ...”..‡.¿..Õ.......................................®..—ß..À...«..—¥.....................................´..ß÷Ë..¡..’™...Õ◊Ë ...π...“.¬....°......‡.ª..πì...º..Ÿâ∂..◊Õ..°...√..√..¡.. ..‘∑...∏..‘Ï .μ...âÕ..ß..μ..°...Õ..¬..àŸ„..π..

∫...—ß..§..—∫...¿..“..√..–..®..”..¬..Õ..¡...‡.√..Ë◊Õ..ß..∑...“..ß..‡.¥..‘π....∑..“..ß..√..∂...¬..π..μ...å .‰.ø...ø..“Ñ....ª..√..–..ª..“....μ..≈..Õ...¥..®..π.. ...“..∏..“..√..≥...ªŸ ..‚..¿..§..μ...à“..ß..Ê...¢..Õ...ß..∑..¥’Ë..‘π...‚.©..π...¥..∑..Ë’..Ò..Û..ı...Û...´...÷Ëß..‡.ª..ìπ...°..√..√..¡.. ...∑‘ ..∏.‘Ï
¢...Õ..ß..¢..“â..æ...‡.®..“â ...μ...“.¡...§..”.. ..—ßË..»...“.≈.../..§..”..æ..æ‘...“..°..…..“..»...“.≈.......................................§...¥..À’..¡...“..¬..‡.≈..¢...·..¥..ß..∑....Ë’ ..........................≈...ß..«..—π..∑...’Ë.................‡.¥...◊Õ..π..............................................æ....»........................................

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¢âÕ Ú. ©–ππ—È ¢Õ„À‡â ®“â æπ°— ß“π∑¥Ë’ π‘ ..‰..¥..â‚.ª...√..¥..®..¥...∑..–..‡.∫...’¬..π..¿...“..√..–..®..”..¬..Õ..¡...„.À..âμ...“..¡..§..«..“..¡..ª...√..–.. ..ß..§...¢å ..Õ..ß..¢..“â..æ...‡.®..â“..¥..â«..¬...................

.....................................................................................................................................................................................................

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.......................π..“..¬....¢.......................... ºŸâ¢Õ
........................................................ 欓π
........................................................ 欓π

μ«— Õ¬à“ßÀ¡“¬‡≈¢ Ù

 “√∫≠— ®¥∑–‡∫’¬π

(‚©π¥∑‡Ë’ ªìπ¿“√¬∑√æ— ¬å)

®¥∑–‡∫¬’ π ª√–‡¿∑°“√ ºŸâ„À â ≠— ≠“ ºŸâ√—∫ —≠≠“ ‡πÈ◊Õ∑’Ë¥‘π ‡πÈ◊Õ∑’Ë¥‘π √–«“ß ‡®â“æπ—°ß“π∑Ë’¥‘π
«π— ‡¥Õ◊ π ªï ®¥∑–‡∫’¬π μ“¡ ≠— ≠“ §ß‡À≈Õ◊ ‡≈¢∑’Ë¥‘π ≈ß≈“¬¡Õ◊ ™Õ◊Ë
‚©π¥∑’Ë¥π‘ „À¡à ª√–∑∫— μ√“
‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
«“ «“

«π— ∑’.Ë ................. ¿“√–®”¬Õ¡∫“ß à«π ∑Ë¥’ ‘π·ª≈ßπÈ’ ∫“ß «à πμ°‡ªìπ¿“√–®”¬Õ¡‡√ÕË◊ ß∑“߇¥π‘ ∑“ß√∂¬πμå ‰øøÑ“ ª√–ª“ (≈ß™Ë◊Õ).........................
‡¥◊Õπ................ (μ“¡§” Ë—ß»“≈/ μ≈Õ¥®π “∏“√≥ªŸ ‚¿§μà“ßÊ ¢Õß∑Ë’¥‘π‚©π¥∑’Ë ÒÛıÛ Õ”‡¿Õ...............®ß— À«¥— .............
æ.»................... §”æ‘æ“°…“»“≈....... μ“¡§” Ëß— »“≈/§”æ‘æ“°…“»“≈......................§¥À’ ¡“¬‡≈¢·¥ß∑Ë’..............≈ß«π— ∑.Ë’ ............

§¥À’ ¡“¬‡≈¢·¥ß∑.Ë’ . ‡¥Õ◊ π......................æ.». ........·≈–μ“¡§”¢Õ©∫∫— ∑.Ë’ ..........‡¥◊Õπ...........................æ.». ............
............≈ß«π— ∑.Ë’ ............
‡¥◊Õπ............................
æ.». .....................)

Ò˜

Ò¯

μ«— Õ¬“à ßÀ¡“¬‡≈¢ ı (∑.¥. Ò)

∑∫’Ë “â π

(‚©π¥∑‡’Ë ªπì ¿“√¬∑√æ— ¬)å ∑ ’Ë «π/‰√à

∑’Ëπ“

¿“√–®”¬Õ¡∫“ß à«π‡√◊ËÕß∑“߇¥‘π ∑“ß√∂¬πμå ‰ø Ñø“ ª√–ª“ μ≈Õ¥®π “∏“√≥Ÿª‚¿§μà“ßÊ ´÷Ë߉¥â®¥∑–‡∫’¬π‰«âμ“¡∫—π∑÷°¢âÕμ°≈ß©∫—∫≈ß«—π∑Ë’.......‡ ◊¥Õπ...........æ.»...........∫—¥π’È §àŸ°√≥’‰ â¥μ°≈ß°—π ∑’Ë..............
„Àⷰ≢‡ª≈Ë’¬π·ª≈ß¿“√–®”¬Õ¡∫“ß à«π ‚¥¬¬â“¬‰ªÕ¬àŸ∑“ß∑‘»..................° ⫓ߪ√–¡“≥..................¬“«ª√–¡“≥..................μ“¡∫—π∑÷°¢âÕμ°≈ß©∫—∫≈ß«—π∑Ë’.......‡ ◊¥Õπ...........æ.»...........
‡®â“æ —π°ß“π Ë’∑¥‘𠧔¢Õ®¥∑–‡∫’¬π ∑‘ ∏·‘ ≈–π‘μ°‘ √√¡ πÕ°‡¢μ

·≈–°“√ Õ∫ «π ‘∑∏‘„π∑¥Ë’ ‘π ª√–‡¿∑..·...°..â‰.¢...‡.ª..≈...¬’Ë ..π..·..ª...≈..ß..¿...“.√..–..®..”..¬...Õ.¡ „π‡¢μ

μ”·Àπàß∑Ë’¥‘π

√–«“ß......................................................................................... μ”∫≈.........................................................................................

‡≈¢∑¥’Ë π‘ ..................................................................................... Õ”‡¿Õ........................................................................................

Àπ“â  ”√«®..................................................................................®—ßÀ«—¥........................................................................................

‚©π¥∑’Ë¥‘π ÒÛı
‡≈¢∑’.Ë .....................Ò...Û..ı..Û...............‡≈¡à ........................................Àπâ“....................................

®”π«π∑¥Ë’ π‘ ...................................‰√à.................................ß“π...................................μ“√“ß«“

Ò. ¢â“懮“â ºâŸ¡π’ “¡μÕà ‰ªπ’È ¡’§«“¡ª√– ß§å¢Õ®¥∑–‡∫’¬π ∑‘ ∏‘·≈–πμ‘ ‘°√√¡‡°Ë’¬«°—∫Õ ß— À“√¡‘ ∑√—æ¬å∑Ë’°≈“à «¢“â ß∫ππ’È ·≈–

‰¥ªâ Ø‘≠“≥μπ·≈«â ¢Õ„À∂â Õâ ¬§”¥«â ¬§«“¡ μ— ¬å®√‘ß ∂â“¢â“懮ⓄÀ∂â Õâ ¬§”‰¡à‡ªπì §«“¡®√ß‘ „Àâ„™∂â âÕ¬§”πÈ’¬π— ¢â“懮“â „π∑“ߧ¥Õ’ “≠“‰¥â

Ú. ¢â“懮â“....π..“..¬...°......‡.®..“â..¢..Õ..ß...¿..“..√..¬..∑..√..—æ...¬..å.... ‡≈¢ª√–®”μ—«ª√–™“™π ºŸâ...¢..Õ.................................

.................................................

Õ“¬.ÿ .................................ªï  ≠— ™“μ‘.........................................∫¥‘ “/¡“√¥“™◊ÕË .............................................................................

‚ ¥ À¡“â ¬ § Ÿà ¡√ ™◊ÕË ..........................................................................................

Õ¬Ÿà∑’Ë∫“â π/À¡Ÿà∫â“π..........................‡≈¢∑Ë’................μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡∑àŸ Ë.’ .............

μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®—ßÀ«¥— .................................À¡“¬‡≈¢‚∑√»æ— ∑å.....................

Û. ¢“â 懮“â ...π..“..¬....¢.....‡..®..“â ..¢..Õ..ß.. ..“..¡...¬..∑..√..—æ...¬..å .... ‡≈¢ª√–®”μ—«ª√–™“™π º.⟠..¢..Õ.................................

................................................
Õ“¬ÿ..................................ªï  ≠— ™“μ.‘ ........................................∫‘¥“/¡“√¥“™◊ÕË .............................................................................

‚ ¥ À¡“â ¬ § Ÿà ¡√ ™Ë◊Õ....................................................... —≠™“μ.‘ ......................
Õ¬Ÿà∑∫Ë’ â“π/À¡∫Ÿà â“π..........................‡≈¢∑Ë’................μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡à∑Ÿ Ë’..............
μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®—ßÀ«¥— .................................À¡“¬‡≈¢‚∑√»—æ∑.å ....................

Ù. ¢“â 懮“â ¢Õ· ¥ß√“§“∑√—æ¬∑å ¢Ë’ Õ∑”πμ‘ °‘ √√¡π‡’È ªìπ‡ß‘π.............................›............................∫“∑.........›........... μ“ߧå
ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à

(Ò) ¢â“懮Ⓣ¡à‰¥â√—∫‚Õπ·∑πÀ√Õ◊ ‡æË◊Õª√–‚¬™πå·°∫à §ÿ §≈μà“ߥ“â «
(Ú) √“§“∑√æ— ¬å∑’·Ë  ¥ß‰«â„π Ù. ‡ªìπ√“§“∑’Ë·∑â®√ß‘
(Û) .....................................................................................................................................................................
(Ù) .....................................................................................................................................................................
(ı) .....................................................................................................................................................................

«π— ∑.Ë’ ...........‡¥Õ◊ π..............................æ.»..................
≈ß™ËÕ◊ .....................π..“..¬...°...........................ºâŸ¢Õ ‡®“â ¢Õß¿“√¬∑√æ— ¬å
≈ß™ÕË◊ .....................π..“..¬...¢..........................ºŸâ¢Õ ‡®“â ¢Õß “¡¬∑√æ— ¬å
≈ß™ËÕ◊ ......................................................º âŸ Õ∫ «π

(......................................................)
 ”À√—∫æπ°— ß“π‡®“â Àπ“â ∑Ë’
Ò) √“§“ª√–‡¡‘π∑πÿ ∑√æ— ¬å.....................................................................................................∫“∑........................................ μ“ߧå
Ú) ‚©π¥∑’¥Ë π‘ „À¡à√–«“ß............................................‡≈¢∑¥’Ë π‘ ...............................................Àπâ“ ”√«®.........................................
‚©π¥∑¥’Ë ‘π‡≈¢∑’.Ë ..................................................‡≈¡à ......................................................Àπâ“..................................................
®”π«π∑¥Ë’ π‘ ......................................................‰√.à ................................................ß“π..................................................μ“√“ß«“
§ß‡À≈Õ◊ ...........................................................‰√.à ................................................ß“π..................................................μ“√“ß«“
Û) ‰¥â®¥∑–‡∫’¬π·≈â«·μà«π— ∑Ë.’ ................................‡¥◊Õπ............................................æ.»......................

≈ß™◊ËÕ.......................................................
(......................................................)
‡®â“æπ—°ß“π∑’Ë¥‘π

μ—«Õ¬“à ßÀ¡“¬‡≈¢ ı Ò˘
(‚©π¥∑’ˇªπì ¿“√¬∑√æ— ¬)å
(∑.¥. Òˆ)

∫—π∑°÷ ¢âÕμ°≈߇√◊ÕË ß·°â‰¢‡ª≈¬’Ë π·ª≈ß¿“√–®”¬Õ¡

∑Ë’¥‘π

√–«“ß...............................................................................μ”∫≈........................................................................

‡≈¢∑¥Ë’ ‘π...............................Àπ“â  ”√«®............................Õ”‡¿Õ.......................................................................
‚©π¥À¡“¬‡≈¢∑.Ë’ ..................ÒÒ..ÛÛ..ıı...Û.....................................®ß— À«—¥.......................................................................

∑Ë’«à“°“√.....................................................................

«—π∑’Ë................‡¥◊Õπ........................................æ.». ....................

¢“â 懮“â .....................π..“..¬....°.......‡.®..“â..¢..Õ..ß..¿...“..√..¬..∑..√..—æ...¬..å .................................. ‡≈¢ª√–®”μ—«ª√–™“™π

.....................π..“..¬....¢.......‡.®..“â ..¢..Õ..ß.. ...“..¡..¬..∑..√..æ—...¬..å ..................................

Õ“¬ÿ...................ªï ‡™Õ◊È ™“μ‘............................... ≠— ™“μ.‘ ..............................∫¥‘ “/¡“√¥“™Õ◊Ë ............................................................

Õ¬àŸ∑’∫Ë “â π/À¡∫àŸ “â π......................................‡≈¢∑’.Ë .............μ√Õ°/´Õ¬.....................................∂ππ.................................À¡∑Ÿà Ë’..........

μ”∫≈/·¢«ß...............................Õ”‡¿Õ/‡¢μ...............................®—ßÀ«¥— ................................À¡“¬‡≈¢‚∑√»—æ∑å..............................
¢//Õ//ª//Ø//≠‘ //“/≥///μ//π//·/≈//–//„/À//â∂//âÕ//¬/§//”//μ/àÕ//......‰.¥..â∑...”..∫..π—..∑...°÷ ..¢..âÕ..μ...°..≈..ß..μ...Õà ..‡.®..“â..æ...π..°—..ß..“..π..∑...Ë¥’ ..‘π.....................................................................................

¥//«â//¬//§//«/“/¡// //—μ//¬//å®/√//ß‘ / ¥ß— μàÕ‰ªπÈ’ :›
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.æ....».................‚.¥...¬..„..À..∑â...’¥Ë ..‘π...·..ª...≈..ß..‚..©..π...¥..∑...’Ë .Ò...Û..ı......Õ...”..‡.¿...Õ...................®..—ß..À...«..—¥.................μ...°..Õ..¬...Ÿà„.π...∫..ß—...§..—∫...¿..“..√..–..®...”..¬..Õ..¡....‡..√..Õ◊Ë..ß...∑..“..ß..‡.¥...π‘....∑...“.ß...√..∂..¬...π..μ..å......
.‰.ø...ø..“Ñ....ª..√..–...ª..“....μ..≈...Õ..¥...®..π.. ...“..∏..“..√..≥...Ÿª...‚.¿...§..μ...“à..ß..Ê....¢..Õ...ß..∑..’Ë¥...‘π..‚..©..π...¥..∑...’Ë .Ò...Û..ı..Û....Õ...”..‡.¿...Õ...............................................®..—ß..À...«..—¥..........................................................∑..“..ß..∑...»‘ ...............................................
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.‰.ª..Õ...¬..àŸ∑...“..ß..∑..‘»......................................°...«..â“..ß..ª..√...–..¡..“..≥................................¬..“..«..ª...√..–..¡..“..≥................................·..≈...«â ...ª...√..“..°..Ø...μ..“..¡...√..ªŸ ..·...º..π...∑..Ë’μ...Õà ..∑...“â ..¬..¢..âÕ...μ..°...≈..ß..π...È’ .
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............................................................................................≈..ß...™..◊ËÕ...........................................................π......“....¬.........°.......................................................‡.®..â“..¢...Õ..ß..¿...“..√..¬..∑...√..æ— ...¬..å ...................
............................................................................................≈..ß...™..Ë◊Õ...........................................................π......“....¬.........¢......................................................‡.®..“â..¢...Õ..ß.. ...“..¡..¬...∑..√..æ—...¬..å...................
............................................................................................≈..ß...™..◊ËÕ....................................................................................................................................æ...¬..“..π...........................................
............................................................................................≈..ß...™..Ë◊Õ.....................................................................................................................................æ...¬..“..π...........................................
.............................∫...—π..∑...÷°..¢..Õâ...μ..°...≈..ß..π...È’‰..¥..∑â...”..μ..Õà...À..π...“â ......................................................................................................................................
............................................................................................≈..ß...™..Ë◊Õ.....................................................................................................................................‡.®..“â..æ...π...°— ..ß..“..π..∑...¥’Ë..π‘..........................
..........................................................................................................ª..√..–..∑...—∫..μ...√..“..μ...”.·...À..π...àß..‡.ª...πì .. ...”..§..≠—..........................................................

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ÒÒ μ«— Õ¬“à ßÀ¡“¬‡≈¢ ı

N ·ºπ∑∑Ë’ ⓬∫—π∑°÷ ¢Õâ μ°≈߇√Õ◊Ë ß·°â‰¢‡ª≈ˬ’ π·ª≈ß¿“√–®”¬Õ¡
▼ ‚©π¥‡≈¢∑’Ë ÒÛı ‡≈¢∑’¥Ë ‘π................Àπâ“ ”√«®..............
μ”∫≈....................Õ”‡¿Õ...................®ß— À«¥— ....................

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///////////////// ‡¢μ∑Ë¥’ ‘π ‚©π‹ ¥∑’Ë ÒÛı ‡πÈÕ◊ ∑.Ë’ ..................‰√à
‡¢μ ·’ ¥ß ‡ªπì ‡¢μ∑’Ë®¥∑–‡∫’¬π·°â‰¢‡ª≈’ˬπ·ª≈ß¿“√–®”¬Õ¡
°«“â ߪ√–¡“≥.............................¬“«ª√–¡“≥........................
√«¡‡πÈÕ◊ ∑ªË’ √–¡“≥......................‰√à

≈ß™Õ◊Ë .......................π..“..¬....°.......................‡®â“¢Õß¿“√¬∑√—æ¬å
≈ß™Õ◊Ë .......................π..“..¬....¢........................‡®â“¢Õß “¡¬∑√—æ¬å
≈ß™ÕË◊ ......................................................欓π
≈ß™Õ◊Ë ......................................................欓π
≈ß™ÕË◊ ......................................................‡®“â æπ°— ß“π∑’¥Ë ‘π

μ«— Õ¬à“ßÀ¡“¬‡≈¢ ı

 “√∫≠— ®¥∑–‡∫’¬π

(‚©π¥∑’‡Ë ªπì ¿“√¬∑√æ— ¬å)

®¥∑–‡∫¬’ π ª√–‡¿∑°“√ ºâŸ„À â ≠— ≠“ ºâŸ√—∫ —≠≠“ ‡π◊ÈÕ∑’Ë¥‘π ‡π◊ÈÕ∑Ë’¥‘π √–«“ß ‡®â“æπ—°ß“π∑Ë’¥‘π
«π— ‡¥Õ◊ π ªï ®¥∑–‡∫¬’ π μ“¡ ≠— ≠“ §ß‡À≈Õ◊ ‡≈¢∑’Ë¥‘π ≈ß≈“¬¡Õ◊ ™Õ◊Ë
‚©π¥∑’Ë¥‘π„À¡à ª√–∑∫— μ√“
‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
«“ «“

«π— ∑Ë.’ ................. ·°â‰¢‡ª≈¬Ë’ π·ª≈ß ¿“√–®”¬Õ¡∫“ß à«π‡√ÕË◊ ß∑“߇¥π‘ ∑“ß√∂¬πμå ‰øøÑ“ ª√–ª“ μ≈Õ¥®π (≈ß™Õ◊Ë ).........................
‡¥◊Õπ................ ¿“√–®”¬Õ¡  “∏“√≥Ÿª‚¿§μ“à ßÊ ´Ë÷߉¥â®¥∑–‡∫’¬π‰«μâ “¡∫—π∑÷°¢Õâ μ°≈ß©∫∫— ≈ß«π— ∑Ë’..........
æ.». .................. ‡¥Õ◊ π..................æ.». ........∫¥— πÈ’§°Ÿà √≥’‰¥âμ°≈ß„Àⷰ≢‡ª≈’¬Ë π·ª≈ß¿“√–®”¬Õ¡
∫“ß à«π‚¥¬¬“â ¬‰ªÕ¬∑Ÿà “ß∑»‘ .................°«â“ߪ√–¡“≥..............¬“«ª√–¡“≥.............
μ“¡∫—π∑°÷ ¢âÕμ°≈ß©∫—∫≈ß«π— ∑’Ë.............‡¥◊Õπ................................æ.». ............

ÒÒÒ

ÒÒÚ

μ—«Õ¬“à ßÀ¡“¬‡≈¢ ˆ (∑.¥. Ò)

∑∫’Ë “â π

(‚©π¥∑ˇ’ ªìπ “¡¬∑√—æ¬å) ∑’ Ë «π/‰√à

∑Ë’π“

∑.Ë’ .............

§”¢Õ®¥∑–‡∫¬’ π ∑‘ ∏‘·≈–π‘μ‘°√√¡ πÕ°‡¢μ
·≈–°“√ Õ∫ «π ‘∑∏‘„π∑¥’Ë π‘ ª√–‡¿∑...¿...“..√..–..®..”..¬..Õ..¡.......................... „π‡¢μ

μ”·Àπàß∑Ë’¥‘π

√–«“ß.........................................................................................μ”∫≈.........................................................................................

‡≈¢∑Ë¥’ ‘π.....................................................................................Õ”‡¿Õ........................................................................................
Ë∑’¥‘π‚©π¥∑Ë’ ÒÛıÛ Õ”‡¿Õ..................... —®ßÀ«—¥.....................‡ ìªπ “¡¬∑√—æ¬å‡√◊ËÕß∑“߇¥‘π ∑“ß√∂¬πμå ‰ø Ñø“ ª√–ª“ μ≈Õ¥®π “∏“√≥Ÿª‚¿§μà“ßÊ
¢Õß∑Ë’ ‘¥π‚©π¥∑Ë’ ÒÛı Õ”‡¿Õ..................... —®ßÀ«—¥.....................μ“¡∫—π∑÷° â¢Õμ°≈ß©∫—∫≈ß«—π∑Ë’.........‡ ◊¥Õπ.....................æ.»...............Àπâ“ ”√«®..................................................................................®ß— À«¥— ........................................................................................
‡®â“æπ—°ß“π ’Ë∑ ‘¥π
‚©π¥∑¥’Ë ‘π ÒÛıÛ
‡≈¢∑.Ë’ .....................Ò...Û..ı.................‡≈¡à ........................................Àπ“â ....................................

®”π«π∑¥’Ë π‘ ...................................‰√à.................................ß“π...................................μ“√“ß«“

Ò. ¢“â 懮“⠺⡟ ’π“¡μÕà ‰ªπÈ’ ¡§’ «“¡ª√– ß§¢å Õ®¥∑–‡∫¬’ π ∑‘ ∏·‘ ≈–πμ‘ °‘ √√¡‡°Ë’¬«°—∫Õ ß— À“√‘¡∑√—æ¬å∑°Ë’ ≈“à «¢“â ß∫ππ’È ·≈–

‰¥ªâ Ø‘≠“≥μπ·≈«â ¢Õ„À∂â âÕ¬§”¥â«¬§«“¡ —쬮å √ß‘ ∂â“¢â“懮ⓄÀ∂â âÕ¬§”‰¡‡à ªì𧫓¡®√ß‘ „Àâ„™∂â Õâ ¬§”π¬’È —π¢“â 懮Ⓞπ∑“ߧ¥’Õ“≠“‰¥â

Ú. ¢“â 懮â“....π..“..¬...¢......‡.®..“â..¢..Õ..ß.. ...“..¡..¬..∑...√..—æ..¬..å.... ‡≈¢ª√–®”μ—«ª√–™“™π ºâ.Ÿ ..¢..Õ.................................

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Õ“¬.ÿ .................................ªï  ≠— ™“μ‘.........................................∫¥‘ “/¡“√¥“™ËÕ◊ .............................................................................

‚ ¥ À¡“â ¬ § àŸ ¡√ ™ÕË◊ ..........................................................................................

Õ¬àŸ∑’Ë∫â“π/À¡Ÿ∫à “â π..........................‡≈¢∑.Ë’ ...............μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡∑Ÿà Ë.’ .............

μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®—ßÀ«—¥.................................À¡“¬‡≈¢‚∑√»æ— ∑.å ....................

Û. ¢â“懮“â ...π..“..¬....¢.....‡..®..“â ..¢..Õ..ß..¿..“..√..¬...∑..√..—æ..¬...å .... ‡≈¢ª√–®”μ—«ª√–™“™π ºâ.Ÿ ..¢..Õ.................................

................................................
Õ“¬.ÿ .................................ªï  ≠— ™“μ‘.........................................∫‘¥“/¡“√¥“™ËÕ◊ .............................................................................

‚ ¥ À¡“â ¬ §à Ÿ ¡√ ™ËÕ◊ ....................................................... ≠— ™“μ‘.......................
Õ¬∑Ÿà ’Ë∫â“π/À¡Ÿ∫à “â π..........................‡≈¢∑’Ë................μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡à∑Ÿ Ë.’ .............
μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®—ßÀ«—¥.................................À¡“¬‡≈¢‚∑√»æ— ∑.å ....................

Ù. ¢â“懮“â ¢Õ· ¥ß√“§“∑√—æ¬∑å ’Ë¢Õ∑”πμ‘ °‘ √√¡π’ȇªìπ‡ßπ‘ .............................›............................∫“∑.........›........... μ“ߧå
ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à

(Ò) ¢â“懮Ⓣ¡à‰¥â√∫— ‚Õπ·∑πÀ√◊Õ‡æ◊ËÕª√–‚¬™π·å °à∫ÿ§§≈μ“à ߥ“â «
(Ú) √“§“∑√æ— ¬å∑Ë·’  ¥ß‰«â„π Ù. ‡ªìπ√“§“∑Ë’·∑â®√‘ß
(Û) .‰.¡..à¡...’§..“à..μ..Õ...∫..·..∑...π...(..¡..§’..à“..μ...Õ..∫..·...∑..π..‡..ª..πì..‡..ß..π‘ ........................................................∫..“..∑..)............................................................................
(Ù) .....................................................................................................................................................................
(ı) .....................................................................................................................................................................

«π— ∑.Ë’ ...........‡¥Õ◊ π..............................æ.»..................
≈ß™ÕË◊ .....................π..“..¬...¢...........................ºâŸ¢Õ ‡®“â ¢Õß “¡¬∑√æ— ¬å
≈ß™◊ÕË .....................π..“..¬...°..........................ºŸâ¢Õ ‡®â“¢Õß¿“√¬∑√æ— ¬å
≈ß™Ë◊Õ......................................................º Ÿâ Õ∫ «π

(......................................................)
 ”À√∫— æπ°— ß“π‡®“â Àπâ“∑Ë’
Ò) √“§“ª√–‡¡‘π∑ÿπ∑√æ— ¬å.....................................................................................................∫“∑........................................ μ“ߧå
Ú) ‚©π¥∑’¥Ë π‘ „À¡√à –«“ß............................................‡≈¢∑’Ë¥π‘ ...............................................Àπ“â  ”√«®.........................................
‚©π¥∑Ë’¥π‘ ‡≈¢∑’Ë...................................................‡≈¡à ......................................................Àπ“â ..................................................
®”π«π∑¥’Ë π‘ ......................................................‰√.à ................................................ß“π..................................................μ“√“ß«“
§ß‡À≈Õ◊ ...........................................................‰√.à ................................................ß“π..................................................μ“√“ß«“
Û) ‰¥®â ¥∑–‡∫¬’ π·≈â«·μà«—π∑Ë.’ ................................‡¥Õ◊ π............................................æ.»......................

≈ß™◊ÕË .......................................................
(......................................................)
‡®â“æπ—°ß“π∑Ë’¥‘π

μ«— Õ¬“à ßÀ¡“¬‡≈¢ ˆ ÒÒÛ
(‚©π¥∑ˇ’ ªìπ “¡¬∑√æ— ¬å)
(∑.¥. Òˆ)

∫π— ∑°÷ ¢Õâ μ°≈߇√ÕË◊ ß¿“√–®”¬Õ¡

∑’Ë¥‘π

√–«“ß...............................................................................μ”∫≈........................................................................
‡≈¢∑Ë¥’ ‘π...............................Àπ“â  ”√«®............................Õ”‡¿Õ.......................................................................
‚©π¥À¡“¬‡≈¢∑Ë’..................Ò...Û..ı..Û......................................®—ßÀ«—¥.......................................................................

ÒÛı
∑Ë’«à“°“√.....................................................................

«π— ∑.’Ë ...............‡¥◊Õπ........................................æ.».....................

¢“â 懮“â .....................π..“..¬....¢......‡.®..â“..¢..Õ..ß.. ...“..¡..¬..∑..√..æ—...¬..å.................................. ‡≈¢ª√–®”μ—«ª√–™“™π

.....................π..“..¬....°.......‡.®..“â..¢..Õ..ß..¿...“..√..¬..∑..√..—æ...¬..å ..................................

Õ“¬.ÿ ..................ªï ‡™Õ◊È ™“μ.‘ .............................. —≠™“μ.‘ ..............................∫¥‘ “/¡“√¥“™Ë◊Õ............................................................

Õ¬∑Ÿà ∫’Ë â“π/À¡∫àŸ “â π......................................‡≈¢∑.Ë’ .............μ√Õ°/´Õ¬.....................................∂ππ.................................À¡Ÿà∑.Ë’ .........

μ”∫≈/·¢«ß...............................Õ”‡¿Õ/‡¢μ...............................®—ßÀ«¥— ................................À¡“¬‡≈¢‚∑√»—æ∑å..............................

¢//Õ//ª//Ø//≠‘ //“/≥///μ//π//·/≈//–//„/À//â∂//Õâ //¬/§//”//μ/àÕ//......‰.¥..∑â...”..∫..π—..∑...÷°..¢..Õâ..μ...°..≈..ß..μ...Õà ..‡.®..“â..æ...π..—°..ß..“..π..∑...’¥Ë ..‘π.....................................................................................

¥//â«//¬//§//«/“/¡// //μ—//¬//®å /√//‘ß/ ¥—ßμÕà ‰ªπ’È :›
......................¢..âÕ....Ò.......∑...¥Ë’ ..π‘...μ..“..¡...‡.§...√..◊ÕË ..ß..À...¡..“..¬...¥..—ß..°...≈..à“..«..¢...â“.ß...∫..π...π..È’..‡.ª...ìπ.. ..“..¡...¬..∑...√..æ—...¬..å·..≈...–..¿..“..√...¬..∑..√...—æ..¬...·å ..°..à°...—π....‚.¥...¬..¢..â“..æ...‡.®..“â....π..“..¬....¢......‡.®..â“..¢...Õ..ß......
.∑..¥Ë’...‘π..‚.©...π..¥...∑..’Ë..Ò..Û...ı..Û....Õ...”..‡.¿..Õ.....................................®..—ß..À...«..—¥...............................‰.¥...√â ..—∫..ª...√..–..‚..¬..™..π...‡å.√..ÕË◊...ß..∑...“.ß...‡.¥..π‘....∑...“..ß..√..∂...¬..π..μ...å.‰..ø...ø..Ñ“....ª..√..–...ª..“....μ..≈..Õ...¥..®... ..“..∏..“..√..≥....Ÿª..‚..¿..§.....
.μ..à“..ß..Ê....¢..Õ...ß..∑..Ë’¥...‘π..‚..©..π...¥..∑...’Ë .Ò...Û..ı.......Õ..”..‡.¿...Õ......................................................................®..ß—...À..«..—¥.....................................................................´..Ë÷ß..‰..¥..â®..¥...∑..–...‡.∫...’¬..π..¿...“..√..–..®..”..¬...Õ..¡...‰.«..â„..π..‚..©..π...¥..∑...’Ë .Ò...Û..ı......
.Õ..”..‡.¿...Õ......................................................................®..ß—...À..«..—¥..............................................................................·..≈...â«......................................................................................................................
......................¢..âÕ....Ú.......°...“..√..¢..Õ...®..¥..∑...–..‡.∫...¬’ ..π...¿..“..√..–..®...”..¬..Õ...¡..¥...—ß..°..≈...à“.«...‰.¡..¡à...§’..à“..μ...Õ..∫...·..∑...π....(.¡...’§..“à..μ...Õ..∫...·..∑..π...‡.ª...πì ..‡..ß..π‘ ......................................∫...“..∑..)..........................
......................¢..Õâ....Û.......¢...Õ..‡.®...â“..æ..π...°— ..ß..“..π...∑..¥Ë’...‘π..‰..¥..â‚..ª..√..¥...®..¥...∑..–..‡..∫..’¬...π..„.À...μâ..“..¡...§..«..“..¡...ª..√...–.. ..ß..§...å¢..Õ...ß..¢..“â..æ...‡.®..â“..¥...â«..¬....¢..â“..æ...‡.®..“â..¬..Õ...¡..‡.. ..’¬...§..“à..∏..√...√..¡..‡.π...¬’..¡.....
.„.À..âμ...“..¡..√..–...‡.∫...’¬..∫...........................................................................................................................................................................................
......................∫...π— ..∑...°÷ ..¢..âÕ...μ..°...≈..ß..π...∑È’ ..”..‰..«..â .Ò....©...∫..∫—....‡..°..∫Á...‰.«..â..≥..... ..”..π..—°...ß..“..π..∑...¥’Ë ..‘π....∑...—Èß.. ..Õ...ß..Ω...“É .¬...‰.¥...μâ ..√..«...®..¥..Ÿ∫...—π..∑...°÷ ..¢..Õâ...μ..°...≈..ß..·...≈..–..‡..¢..“â..„.®...¢..âÕ..§...«..“..¡...........
.μ..≈..Õ...¥..·...≈..«â....®..÷ß..‰..¥..â≈...ß..≈..“..¬...¡..Õ◊...™..ÕË◊ ..À...√..Õ◊ ..æ...‘¡..æ...å≈...“..¬..π..«È‘..¡...◊Õ..‰..«..‡â.ª...ìπ..À...≈..°—...∞..“..π..μ...Õà ..À...π..â“..æ...¬..“..π...·..≈..–...‡.®..“â..æ...π..—°...ß..“..π..∑...¥Ë’ ..π‘.....................................................

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............................................................................................≈..ß...™..Ë◊Õ..................................π...“...¬.....¢...............................‡.®..“â..¢...Õ..ß.. ...“..¡..¬...∑..√..æ—...¬..å...................
............................................................................................≈..ß...™..◊ËÕ..................................π...“...¬.....°...............................‡.®..â“..¢...Õ..ß..¿...“..√..¬..∑...√..æ— ...¬..å ...................

............................................................................................≈..ß...™..◊ËÕ...........................................................................æ...¬..“..π...........................................

............................................................................................≈..ß...™..Ë◊Õ............................................................................æ...¬..“..π...........................................

.............................∫...—π..∑...÷°..¢..âÕ...μ..°...≈..ß..π...È’‰..¥..∑â...”..μ..Õà...À..π...“â ......................................................................................................................................

............................................................................................≈..ß...™..Ë◊Õ............................................................................‡.®..“â..æ...π...°— ..ß..“..π..∑...¥Ë’..π‘..........................

..........................................................................................................ª..√..–..∑...∫—..μ...√..“..μ...”.·...À..π...ßà ..‡.ª...ìπ.. ...”..§..≠—..........................................................

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μ—«Õ¬“à ßÀ¡“¬‡≈¢ ˆ ÒÒÙ

 “√∫≠— ®¥∑–‡∫’¬π

(‚©π¥∑‡Ë’ ªπì  “¡¬∑√æ— ¬å)

®¥∑–‡∫¬’ π ª√–‡¿∑°“√ ºâŸ„À â ≠— ≠“ ºâŸ√—∫ —≠≠“ ‡πÈ◊Õ∑’Ë¥‘π ‡π◊ÈÕ∑Ë’¥‘π √–«“ß ‡®â“æπ—°ß“π∑’Ë¥‘π
«π— ‡¥◊Õπ ªï ®¥∑–‡∫¬’ π μ“¡ —≠≠“ §ß‡À≈Õ◊ ‡≈¢∑Ë’¥‘π ≈ß≈“¬¡Õ◊ ™ÕË◊
‚©π¥∑¥Ë’ ‘π„À¡à ª√–∑∫— μ√“
«π— ∑Ë’.................. ¿“√–®”¬Õ¡ ‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
‡¥Õ◊ π................ «“ «“
æ.». ..................
∑¥Ë’ π‘ ·ª≈ßπ’‡È ªìπ “¡¬∑√æ— ¬‡å √Ë◊Õß∑“߇¥π‘ ∑“ß√∂¬πμå ‰øø“Ñ ª√–ª“ μ≈Õ¥®π (≈ß™ÕË◊ ).........................
 “∏“√≥Ÿª‚¿§μà“ßÊ ¢Õß∑¥’Ë π‘ ‚©π¥∑Ë’ ÒÛı Õ”‡¿Õ.....................®ß— À«—¥...................
μ“¡∫π— ∑÷°¢Õâ μ°≈ß©∫∫— ≈ß«π— ∑Ë’.............‡¥◊Õπ................................æ.». ............

μ—«Õ¬“à ßÀ¡“¬‡≈¢ ˜ ÒÒı

(∑.¥. ˘)

§”¢Õ..·...∫..ßà ..·..¬...°..„.π...“.¡...‡.¥..¡‘....(.§...√..Õ..∫...¿..“..√..–..®..”..¬..Õ..¡...)

©∫∫— ∑.Ë’ ......................................

∑Ë’¥‘π
√–«“ß..................5..1..3..6...I.V.....7.2..2..8..-.1.......................................μ”∫≈.........................................................................................
‡≈¢∑’Ë...................Ò..................................Àπâ“ ”√«®..................Û..Ù...Ù...........................Õ”‡¿Õ..................................................
‚©π¥À¡“¬‡≈¢∑.Ë’ ............Ò...Û..ı..............................................®—ßÀ«—¥.......................................................................................

«π— ∑’Ë................‡¥◊Õπ.....................................æ.». ......................

¢“â 懮â“...........................π..“..¬....°................................................................. ‡≈¢ª√–®”μ—«ª√–™“™π

Õ“¬ÿ...............ªï ‡™◊ÈÕ™“μ.‘ ............................ ≠— ™“μ.‘ ............................∫‘¥“/¡“√¥“™Õ◊Ë .....................................................................

Õ¬àŸ∑’Ë∫â“π/À¡∫àŸ â“π...............................................‡≈¢∑Ë.’ ...................μ√Õ°/´Õ¬............................∂ππ..........................À¡àŸ∑.’Ë ..........

μ”∫≈/·¢«ß..................................Õ”‡¿Õ/‡¢μ..................................®ß— À«¥— ..................................À¡“¬‡≈¢‚∑√»æ— ∑.å ......................

¢Õ¬π◊Ë §”¢ÕμÕà ‡®“â æπ—°ß“π∑’¥Ë ‘π®ß— À«—¥....................................................¥â«¬§«“¡ μ— ¬®å √ß‘ «à“ :-
¢âÕ Ò. ¥«â ¬....¢..â“..æ..‡.®..“â..¡...’™..Ë◊Õ..‡.ª...πì ..º..â∂Ÿ...Õ◊ ..°..√..√..¡.. ...‘∑..∏..∑‘Ï...’¥Ë ..π‘..·...ª..≈..ß..‡..§..√..◊ËÕ..ß..À...¡..“..¬..¢..â“..ß..∫...π..π..È’..‚.¥..¬...À..π..ß—.. ...◊Õ..π..È¢’..“â..æ...‡.®..â“..¡..’§...«..“.¡...ª..√..–.. ...ß..§..å®..–..

·...∫..ßà..·..¬...°..„.π...π..“..¡..‡.¥...¡‘ ..∑..¥Ë’...π‘ ..·..ª...≈..ß..π..’ÈÕ...Õ..°..®..“..°..°...—π..‡.ª...πì ..‹.Ò....·..ª...≈..ß....‚.¥..¬...„.À..â∑...’¥Ë ..π‘..·...ª..≈..ß..·...¬..°..‡.ª...πì ..‚.©...π..¥..„..À..¡...à .·..≈..–...·..ª..≈..ß...§..ß..‡.À...≈..Õ◊ ..¬..ß—...§..ß..μ..°...Õ..¬..àŸ„..π.......
∫...—ß..§..—∫...¿..“..√..–..®..”..¬..Õ..¡...¢..Õ..ß..∑...¥’Ë ..π‘....‚.©..π...¥..‡.≈...¢..∑..’Ë..Ò..Û..ı...Û...Õ...”.‡..¿..Õ...................................®..—ß..À..«..—¥..................................μ..“..¡..∫...π— ..∑..÷°...¢..Õâ ..μ..°...≈..ß..©..∫...∫— ..≈..ß..«..π—...∑..’Ë...........
‡..¥..Õ◊..π......................................æ...».......................´...Ëß÷ ..¢..â“..æ..‡.®..â“..®..–..‰..¥..πâ..”..™..à“..ß..·...º..π..∑...Ë’∑..”..°..“..√..√..ß— ..«..¥— ..ª...°í ..À..≈..—°...‡.¢..μ..„..À..‡â.ª...πì ..°..“..√..·..π...àπ..Õ..π...μ..àÕ..‰..ª............................

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¢âÕ Ú. ©–ππÈ— ¢Õ„À‡â ®“â æπ°— ß“π∑¥’Ë π‘ ...‰..¥..â‚.ª...√..¥..¥...”.‡..π..‘π..°...“.√..„..À..â·..°...¢à ..â“..œ...μ..“..¡...§..«..“..¡..ª...√..–.. ..ß..§..μå...Õà ..‰.ª...¥..â«..¬....·..≈...–..¢..â“..œ...¢..Õ...√..∫— ..√..Õ..ß..«..“à.

∂...â“..∑..¥’Ë ..π‘...√..“.¬...π..¡’È..’‡..¢..μ..§...≈..“..¥..‡.§...≈..◊ÕË..π...¥..«â..¬..ª...√..–..°..“..√..„.¥...Ê...¢..â“..œ....¬..Õ..¡...„.À..â‡.®...â“.æ...π..—°..ß..“..π...·..°..â‰..¢..„.À...â‡.ª..πì...°..“..√..∂..°Ÿ ..μ..âÕ...ß...¢..“â..æ...‡.®..â“..¬..Õ...¡..‡. ..’¬...§..à“..∏..√..√..¡..‡..π..’¬..¡.......
.μ..“..¡..√..–..‡.∫...¬’ ..∫....................................................................................................................................................................................

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.......................π..“..¬....°.......................... ºŸâ¢Õ
........................................................ 欓π
........................................................ 欓π

ÒÒˆ

μ—«Õ¬à“ßÀ¡“¬‡≈¢ ˜ (∑.¥. Ò)
∑∫’Ë “â π

∑Ë ’ «π/‰√à

∑’Ëπ“

∑’.Ë .............

§”¢Õ®¥∑–‡∫’¬π ‘∑∏·‘ ≈–πμ‘ °‘ √√¡ πÕ°‡¢μ
„π‡¢μ

·≈–°“√ Õ∫ «π ∑‘ ∏‘„π∑¥Ë’ π‘ ª√–‡¿∑...·...∫..ßà..·..¬...°..„.π...π..“..¡..‡.¥...¡‘ ............... ·¬° Ò ·≈–

μ”·Àπàß∑Ë’¥‘π (§√Õ∫¿“√–®”¬Õ¡) ·ª≈ߧ߇À≈Õ◊

Ë∑’ ‘¥π·ª≈ß Ë’∑·¬°‰ª ’πÈ·≈–·ª≈ߧ߇À ◊≈Õ¿“√–®”¬Õ¡ —¬ß§ß ’¡Õ Ÿà¬μ“¡ —∫π ÷∑°¢âÕμ°≈ß®¥∑–‡ ’∫¬π¿“√–®”¬Õ¡© —∫∫≈ß«—π ’Ë∑.........‡ ◊¥Õπ.....................æ.»............... √–«“ß.................5..1..3..6...I.V....7..2..2..8..-.1.................................................μ”∫≈.........................................................................................
‡®â“æπ—°ß“π ’Ë∑¥‘π
‡≈¢∑¥Ë’ π‘ .......................Ò..............................................................Õ”‡¿Õ........................................................................................

Àπâ“ ”√«®..................Û...Ù..Ù...........................................................®ß— À«¥— ........................................................................................

‚©π¥∑’Ë¥π‘
‡≈¢∑’Ë.....................Ò..Û..ı...................‡≈à¡........................................Àπ“â ....................................

®”π«π∑Ë’¥‘π...............Ú....................‰√.à .............›...................ß“π...............›....................μ“√“ß«“

Ò. ¢â“懮⓺¡âŸ π’ “¡μàÕ‰ªπ’È ¡§’ «“¡ª√– ß§¢å Õ®¥∑–‡∫’¬π ‘∑∏·‘ ≈–πμ‘ °‘ √√¡‡°’ˬ«°∫— Õ ß— À“√¡‘ ∑√—æ¬∑å Ë’°≈“à «¢“â ß∫ππÈ’ ·≈–

‰¥ªâ Ø≠‘ “≥μπ·≈â« ¢Õ„À∂â âÕ¬§”¥«â ¬§«“¡ —μ¬å®√‘ß ∂â“¢â“懮ⓄÀâ∂âÕ¬§”‰¡‡à ªì𧫓¡®√‘ß„Àâ„™∂â âÕ¬§”π’È¬π— ¢“â 懮“â „π∑“ߧ¥’Õ“≠“‰¥â

Ú. ¢“â 懮“â ..............π..“..¬...°............................. ‡≈¢ª√–®”μ—«ª√–™“™π ºŸâ...∂..Õ◊..°...√..√..¡.. ..‘∑...∏..‘Ï ...............

.................................................

Õ“¬ÿ..................................ªï  ≠— ™“μ.‘ ........................................∫¥‘ “/¡“√¥“™◊ÕË .............................................................................

‚ ¥ À¡“â ¬ § àŸ ¡√ ™ËÕ◊ ..........................................................................................

Õ¬∑Ÿà ∫Ë’ “â π/À¡Ÿà∫â“π..........................‡≈¢∑Ë’................μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡Ÿà∑’.Ë .............

μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«¥— .................................À¡“¬‡≈¢‚∑√»—æ∑å.....................

Û. ¢“â 懮“â ................π..“..¬....°.......................... ‡≈¢ª√–®”μ—«ª√–™“™π º.Ÿâ ..∂...Õ◊ ..°..√..√..¡.. ...‘∑..∏..‘Ï...............

................................................
Õ“¬.ÿ .................................ªï  ≠— ™“μ.‘ ........................................∫¥‘ “/¡“√¥“™ËÕ◊ .............................................................................

‚ ¥ À¡“â ¬ §Ÿà ¡√ ™ËÕ◊ ....................................................... ≠— ™“μ‘.......................
Õ¬Ÿ∑à ’∫Ë â“π/À¡Ÿà∫â“π..........................‡≈¢∑’Ë................μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡Ÿ∑à ’Ë..............
μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«—¥.................................À¡“¬‡≈¢‚∑√»æ— ∑.å ....................

Ù. ¢â“懮ⓢշ ¥ß√“§“∑√—æ¬∑å ¢’Ë Õ∑”πμ‘ ‘°√√¡πȇ’ ªπì ‡ß‘π.............................›............................∫“∑.........›........... μ“ߧå
ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à

(Ò) ¢â“懮“â ‰¡à‰¥â√∫— ‚Õπ·∑πÀ√◊Õ‡æ◊ÕË ª√–‚¬™π·å °∫à §ÿ §≈μ“à ߥ⓫
(Ú) √“§“∑√—æ¬å∑·Ë’  ¥ß‰«â„π Ù. ‡ªπì √“§“∑Ë·’ ∑â®√ß‘
(Û) .·..∫..ßà..·...¬..°..„.π...π..“..¡..‡..¥..¡‘....(.§..√..Õ...∫..¿..“..√..–..®..”..¬...Õ..¡..)...μ..“..¡..§...”..¢..Õ..≈..ß..«..π—...∑..Ë’........................‡..¥..Õ◊..π................................................æ....»................................................
(Ù) .....................................................................................................................................................................
(ı) .....................................................................................................................................................................

«π— ∑.’Ë ...........‡¥Õ◊ π..............................æ.»..................
≈ß™ËÕ◊ .....................π..“..¬...°...........................ºâŸ¢Õ ∂Õ◊ °√√¡ ‘∑∏‘Ï
≈ß™Õ◊Ë .....................π..“..¬...°..........................ºâŸ¢Õ ∂◊Õ°√√¡ ‘∑∏Ï‘
≈ß™◊ÕË ......................................................º âŸ Õ∫ «π

(......................................................)

 ”À√—∫æπ°— ß“π‡®“â Àπ“â ∑’Ë
Ò) √“§“ª√–‡¡‘π∑πÿ ∑√æ— ¬.å ....................................................................................................∫“∑........................................ μ“ߧå
Ú) ‚©π¥∑’Ë¥π‘ „À¡à√–«“ß......5..1..3..6...I..V....7..2.2..8..-..1..............‡≈¢∑’Ë¥‘π.................Ò..............................Àπ“â  ”√«®.........Û..Ù..ı............................

‚©π¥∑Ë’¥‘π‡≈¢∑Ë.’ ....................ˆ..Ú...Û..Û.......................‡≈à¡........................ˆ..Û............................Àπâ“..................Û..Û..............................
®”π«π∑¥Ë’ π‘ ............................Ò..........................‰√.à .............................›...................ß“π..............................›....................μ“√“ß«“
§ß‡À≈Õ◊ .................................Ò..........................‰√.à .............................›...................ß“π..............................›....................μ“√“ß«“
Û) ‰¥â®¥∑–‡∫¬’ π·≈«â ·μ«à π— ∑Ë’.................................‡¥◊Õπ............................................æ.»......................

≈ß™Õ◊Ë .......................................................
(......................................................)
‡®â“æπ—°ß“π∑’Ë¥‘π

μ—«Õ¬“à ßÀ¡“¬‡≈¢ ˜

 “√∫≠— ®¥∑–‡∫¬’ π

(√“¬°“√®¥∑–‡∫’¬π·ª≈߇¥¡‘ ‚©π¥∑’ˇªìπ¿“√¬∑√æ— ¬)å

®¥∑–‡∫¬’ π ª√–‡¿∑°“√ ºŸâ„À â ≠— ≠“ ºâŸ√—∫ —≠≠“ ‡πÈ◊Õ∑Ë’¥‘π ‡π◊ÈÕ∑’Ë¥‘π √–«“ß ‡®â“æπ—°ß“π∑Ë’¥‘π
«π— ‡¥◊Õπ ªï ®¥∑–‡∫¬’ π μ“¡ ≠— ≠“ §ß‡À≈Õ◊ ‡≈¢∑’Ë¥‘π ≈ß≈“¬¡Õ◊ ™Õ◊Ë
‚©π¥∑¥’Ë ‘π„À¡à ª√–∑∫— μ√“
«π— ∑.’Ë ................. ¿“√–®”¬Õ¡ ‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
‡¥Õ◊ π................ «“ «“
æ.». ..................
∑’¥Ë π‘ ·ª≈ßπ’μÈ °Õ¬àŸ„π∫ß— §∫— ¿“√–®”¬Õ¡‡√ÕË◊ ß∑“߇¥π‘ ∑“ß√∂¬πμå ‰øø“Ñ ª√–ª“ (≈ß™Ë◊Õ).........................
μ≈Õ¥®π “∏“√≥ªŸ ‚¿§μà“ßÊ ¢Õß∑’¥Ë π‘ ‚©π¥∑Ë’ ÒÛıÛ Õ”‡¿Õ............®—ßÀ«—¥..............
μ“¡∫—π∑°÷ ¢âÕμ°≈ß©∫—∫≈ß«—π∑’.Ë ........‡¥◊Õπ......................æ.».............

«—π∑Ë’................ ·∫àß·¬°„ππ“¡‡¥¡‘ 𓬠°. 𓬠°. Ò › › Ò › › 5136IV 7228›1 (≈ß™Õ◊Ë ).........................

‡¥Õ◊ π............. (§√Õ∫¿“√–®”¬Õ¡) ∑’¥Ë ‘π·ª≈ß∑Ë’·¬°‰ªπ’È·≈–·ª≈ߧ߇À≈Õ◊ Ò

æ.»................ ¿“√–®”¬Õ¡¬ß— §ß¡Õ’ ¬àŸμ“¡∫π— ∑÷°¢Õâ μ°≈ß ˆÚÛÛ

®¥∑–‡∫¬’ π¿“√–®”¬Õ¡ ©∫—∫≈ß«π— ∑.Ë’ ..........

‡¥Õ◊ π.........................æ.»...................

ÒÒ˜

μ«— Õ¬“à ßÀ¡“¬‡≈¢ ˜ ÒÒ¯

 “√∫≠— ®¥∑–‡∫¬’ π

(√“¬°“√®¥·®âß∑Ë¥’ π‘ ·ª≈ß∑·Ë’ ¬°‰ª„À¡à ‚©π¥‡≈¢∑Ë’ ˆÚÛÛ Õ”‡¿Õ.......)

®¥∑–‡∫¬’ π ª√–‡¿∑°“√ ºâŸ„À â ≠— ≠“ ºâŸ√—∫ —≠≠“ ‡π◊ÈÕ∑Ë’¥‘π ‡π◊ÈÕ∑’Ë¥‘π √–«“ß ‡®â“æπ—°ß“π∑Ë’¥‘π
«π— ‡¥◊Õπ ªï ®¥∑–‡∫’¬π μ“¡ —≠≠“ §ß‡À≈Õ◊ ‡≈¢∑’Ë¥‘π ≈ß≈“¬¡Õ◊ ™Õ◊Ë
‚©π¥∑Ë’¥π‘ „À¡à ª√–∑∫— μ√“
‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
«“ «“

«—π∑’Ë.................. ¿“√–®”¬Õ¡ ∑Ë¥’ π‘ ·ª≈ßπμ’È °Õ¬Ÿà„π∫ß— §—∫¿“√–®”¬Õ¡‡√Ë◊Õß∑“߇¥π‘ ∑“ß√∂¬πμå ‰øøÑ“ ª√–ª“ (≈ß™ÕË◊ ) 𓬠 .
«—π∑’Ë...........................
‡¥Õ◊ π................ (§√Õ∫¿“√–®”¬Õ¡) μ≈Õ¥®π “∏“√≥ªŸ ‚¿§μ“à ßÊ ¢Õß∑’Ë¥π‘ ‚©π¥‡≈¢∑Ë’ ÒÛıÛ Õ”‡¿Õ............................. ‡¥◊Õπ.........................
æ.». ...........................
æ.». .................. ®—ßÀ«—¥....................μ“¡∫—π∑÷°¢âÕμ°≈ß©∫∫— ≈ß«π— ∑’Ë.........‡¥Õ◊ π.....................æ.»............. (≈ß™Õ◊Ë ).....................

μ—«Õ¬à“ßÀ¡“¬‡≈¢ ¯ ÒÒ˘

(∑.¥. ˘)

§”¢Õ..·...∫..ßà ..·..¬...°..„.π...“.¡...‡.¥..¡‘....(.ª...≈..Õ..¥...¿..“..√..–..®..”..¬..Õ...¡..)

©∫—∫∑.Ë’ ......................................

∑’Ë¥‘π
√–«“ß..................5..1..3..6...I.V.....7.2..2..8..-.1.......................................μ”∫≈.........................................................................................
‡≈¢∑Ë’...................Ò..................................Àπâ“ ”√«®..................Û..Ù...Ù...........................Õ”‡¿Õ..................................................
‚©π¥À¡“¬‡≈¢∑’.Ë ............Ò...Û..ı..............................................®ß— À«¥— .......................................................................................

«π— ∑’.Ë ...............‡¥Õ◊ π.....................................æ.». ......................

¢“â 懮â“...........................π..“..¬....°................................................................. ‡≈¢ª√–®”μ—«ª√–™“™π

Õ“¬ÿ...............ªï ‡™ÕÈ◊ ™“μ‘............................. —≠™“μ‘.............................∫‘¥“/¡“√¥“™◊ËÕ.....................................................................

Õ¬à∑Ÿ ’Ë∫â“π/À¡∫àŸ â“π...............................................‡≈¢∑Ë’....................μ√Õ°/´Õ¬............................∂ππ..........................À¡àŸ∑Ë’...........

μ”∫≈/·¢«ß..................................Õ”‡¿Õ/‡¢μ..................................®ß— À«¥— ..................................À¡“¬‡≈¢‚∑√»æ— ∑.å ......................

¢Õ¬◊Ëπ§”¢ÕμÕà ‡®â“æπ°— ß“π∑Ë’¥π‘ ®ß— À«—¥....................................................¥«â ¬§«“¡ —쬮å √ß‘ «à“ :-
¢Õâ Ò. ¥â«¬....¢..â“..æ..‡.®..â“..¡...’™..Õ◊Ë ..‡.ª...ìπ..º..∂âŸ...Õ◊ ..°..√..√..¡.. ...‘∑..∏..‘Ï∑...Ë¥’ ..‘π..·...ª..≈..ß..‡..§..√..ËÕ◊..ß..À...¡..“..¬..¢..â“..ß..∫...π..π..È’..‚.¥..¬...À..π..—ß.. ...◊Õ..π..È’¢..“â..æ...‡.®..â“..¡..’§...«..“.¡...ª..√..–.. ...ß..§..å....

®...–..·..∫..ßà..·...¬..°..„.π...π..“..¡..‡.¥...¡‘ ..∑...Ë’¥..‘π..·...ª..≈..ß..π...ÈÕ’ ..Õ..°..®...“.°...°..—π..‡.ª...πì ..‹..Ò...·...ª..≈..ß....‚.¥...¬..„.À..∑â...’Ë¥..‘π...‡.©..æ...“.–... ..à«..π..∑..·Ë’...∫..ßà..·..¬...°..Õ..Õ..°...‰.ª..‡..ª..πì...‚.©..π..¥...„.À...¡..ªà ..≈...Õ..¥..®..“..°............
¿...“..√..–..®..”..¬..Õ..¡...‰.¥..â.. ..«à..π..·...ª..≈..ß..§...ß..‡.À..≈...◊Õ..¬..ß—..§...ß..¡..¿’..“..√..–..®..”..¬..Õ...¡..μ...¥‘ ..Õ..¬...àŸ .´..Ë÷ß..¢..â“..æ...‡.®..â“..®..–..‰.¥...âπ..”..™..“à..ß..·..º..π...∑..Ë∑’..”..°...“.√..√..ß—..«..¥—...ª..í°..À...≈..°—..‡..¢..μ..„.À...‡â .ª..ìπ...°..“..√..·..π..àπ...Õ.π
μ...Õà ..‰..ª..............................................................................................................................................................................................

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¢Õâ Ú. ©–ππÈ— ¢Õ„À‡â ®“â æπ°— ß“π∑¥’Ë π‘ ..‰.¥...â‚.ª..√..¥...¥..”..‡.π...‘π..°..“..√..„.À...â·..°..¢à..â“..œ....μ..“..¡..§...«..“..¡..ª..√..–.. ...ß..§..μå..Õà...‰.ª...¥..«â..¬....·..≈..–..¢..â“..œ....¢..Õ..√..—∫...√..Õ..ß..«..“à..

∂...“â ..∑..Ë¥’ ..π‘...√..“.¬...π..¡È’..’‡..¢..μ..§...≈..“..¥..‡.§...≈..◊ÕË..π...¥..â«..¬..ª...√..–..°..“..√..„.¥...Ê...¢..“â..œ....¬..Õ..¡...„.À..‡â.®...“â .æ...π..—°..ß..“..π...·..°..â‰..¢..„.À...‡â .ª..πì...°..“..√..∂..Ÿ°..μ..Õâ...ß...¢..â“..æ...‡.®..â“..¬..Õ...¡..‡. ..’¬...§..à“..∏..√..√..¡..‡..π..’¬..¡.......
.μ..“..¡..√..–..‡.∫...¬’ ..∫....................................................................................................................................................................................

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.......................π..“..¬....°.......................... ºŸâ¢Õ
........................................................ 欓π
........................................................ 欓π

ÒÚ

μ—«Õ¬à“ßÀ¡“¬‡≈¢ ¯ (∑.¥. Ò)
∑∫Ë’ “â π

∑ Ë’ «π/‰√à

∑Ë’π“

∑Ë’..............

§”¢Õ®¥∑–‡∫¬’ π ∑‘ ∏·‘ ≈–π‘μ‘°√√¡ πÕ°‡¢μ
„π‡¢μ

·≈–°“√ Õ∫ «π ‘∑∏‘„π∑’Ë¥‘π ª√–‡¿∑...·...∫..ßà..·..¬...°..„.π...π..“..¡..‡.¥...¡‘ ............... ·¬° Ò ·≈–

μ”·Àπàß∑’Ë¥‘π (ª≈Õ¥¿“√–®”¬Õ¡) ·ª≈ߧ߇À≈Õ◊

√–«“ß.................5..1..3..6...I.V....7..2..2..8..-.1................................................. μ”∫≈.........................................................................................

Ë∑’¥‘π·ª≈ß∑Ë’·¬°‰ªπÈ’ âæπ®“°¿“√–®”¬Õ¡ μ“¡∫—π∑÷°¢âÕμ°≈ߪ≈Õ¥¿“√–®”¬Õ¡©∫—∫≈ß«—π∑Ë’.........‡ ◊¥Õπ.....................æ.»...............‡≈¢∑’Ë¥π‘ .......................Ò.............................................................. Õ”‡¿Õ........................................................................................
 à«π·ª≈ߧ߇À ◊≈Õ¿“√–®”¬Õ¡ —¬ß§ß¡’Õ àŸ¬μ“¡ —∫π ÷∑°¢âÕμ°≈ß© —∫∫≈ß«—π Ë’∑.........‡¥◊Õπ.....................æ.»...............
Àπâ“ ”√«®..................Û...Ù..Ù...........................................................®—ßÀ«¥— ........................................................................................
‡ ⮓æπ—°ß“π Ë’∑¥‘π
‚©π¥∑Ë¥’ π‘
‡≈¢∑.Ë’ ....................Ò..Û...ı..................‡≈à¡........................................Àπ“â ....................................

®”π«π∑’Ë¥‘π...............Ú....................‰√.à .............›...................ß“π...............›....................μ“√“ß«“

Ò. ¢“â 懮“â ºŸ¡â π’ “¡μÕà ‰ªπ’È ¡§’ «“¡ª√– ß§å¢Õ®¥∑–‡∫¬’ π ∑‘ ∏‘·≈–π‘μ°‘ √√¡‡°Ë’¬«°∫— Õ ß— À“√¡‘ ∑√—æ¬å∑’Ë°≈à“«¢â“ß∫ππ’È ·≈–

‰¥ªâ Ø≠‘ “≥μπ·≈â« ¢Õ„Àâ∂Õâ ¬§”¥â«¬§«“¡ —μ¬å®√‘ß ∂â“¢â“懮“â „Àâ∂Õâ ¬§”‰¡‡à ªπì §«“¡®√‘ß„Àâ„™â∂âÕ¬§”π¬È’ π— ¢â“懮Ⓞπ∑“ߧ¥Õ’ “≠“‰¥â

Ú. ¢â“懮“â ..............π..“..¬...°............................. ‡≈¢ª√–®”μ—«ª√–™“™π º.Ÿâ ..∂..◊Õ..°...√..√..¡.. ..‘∑...∏..‘Ï ...............

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Õ“¬.ÿ .................................ªï  ≠— ™“μ.‘ ........................................∫¥‘ “/¡“√¥“™◊ËÕ.............................................................................

‚ ¥ À¡“â ¬ §Ÿà ¡√ ™ÕË◊ ..........................................................................................

Õ¬Ÿà∑∫Ë’ “â π/À¡Ÿ∫à â“π..........................‡≈¢∑Ë’................μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡∑Ÿà ’Ë..............

μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«—¥.................................À¡“¬‡≈¢‚∑√»æ— ∑å.....................

Û. ¢â“懮“â ................π..“..¬....°.......................... ‡≈¢ª√–®”μ—«ª√–™“™π ºŸâ...∂..Õ◊...°..√..√..¡.. ...∑‘ ..∏..‘Ï...............

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Õ“¬ÿ..................................ªï  ≠— ™“μ.‘ ........................................∫¥‘ “/¡“√¥“™◊ÕË .............................................................................

‚ ¥ À¡“â ¬ §àŸ ¡√ ™Ë◊Õ....................................................... ≠— ™“μ‘.......................
Õ¬à∑Ÿ ’Ë∫â“π/À¡à∫Ÿ â“π..........................‡≈¢∑Ë.’ ...............μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡Ÿà∑.’Ë .............
μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«¥— .................................À¡“¬‡≈¢‚∑√»—æ∑å.....................

Ù. ¢“â 懮ⓢշ ¥ß√“§“∑√—æ¬∑å ¢’Ë Õ∑”πμ‘ °‘ √√¡πÈ’‡ªìπ‡ßπ‘ .............................›............................∫“∑.........›........... μ“ߧå
ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à

(Ò) ¢“â 懮“â ‰¡à‰¥√â ∫— ‚Õπ·∑πÀ√◊Õ‡æÕ◊Ë ª√–‚¬™π·å °à∫ÿ§§≈μ“à ߥ“â «
(Ú) √“§“∑√—æ¬∑å ’Ë· ¥ß‰«â„π Ù. ‡ªπì √“§“∑Ë’·∑â®√‘ß
(Û) .·..∫..ßà..·...¬..°..„.π...π..“..¡..‡..¥..¡‘....(.ª..≈...Õ..¥..¿...“..√..–..®..”..¬..Õ..¡...)..μ...“.¡...§..”..¢..Õ..≈...ß..«..π— ..∑..Ë’.........................‡.¥..◊Õ...π...............................................æ.....»...............................................
(Ù) .....................................................................................................................................................................
(ı) .....................................................................................................................................................................

«π— ∑.’Ë ...........‡¥Õ◊ π..............................æ.»..................
≈ß™Ë◊Õ.....................π..“..¬...°...........................ºŸâ¢Õ ∂◊Õ°√√¡ ∑‘ ∏‘Ï
≈ß™ËÕ◊ .....................π..“..¬...°..........................ºŸâ¢Õ ∂Õ◊ °√√¡ ∑‘ ∏Ï‘
≈ß™◊ÕË ......................................................º Ÿâ Õ∫ «π

(......................................................)

 ”À√—∫æπ°— ß“π‡®“â Àπâ“∑Ë’
Ò) √“§“ª√–‡¡π‘ ∑πÿ ∑√æ— ¬å.....................................................................................................∫“∑........................................ μ“ߧå
Ú) ‚©π¥∑Ë’¥π‘ „À¡√à –«“ß......5..1..3..6...I.V.....7.2..2..8..-.1...............‡≈¢∑Ë’¥‘π.................Ò..............................Àπâ“ ”√«®.........Û..Ù..ı............................

‚©π¥∑’Ë¥π‘ ‡≈¢∑.Ë’ ....................ˆ..Ú..Û...Û.......................‡≈¡à ........................ˆ..Û............................Àπ“â ..................Û..Û..............................
®”π«π∑¥Ë’ π‘ ............................Ò..........................‰√.à .............................›...................ß“π..............................›....................μ“√“ß«“
§ß‡À≈Õ◊ .................................Ò..........................‰√.à .............................›...................ß“π..............................›....................μ“√“ß«“
Û) ‰¥â®¥∑–‡∫’¬π·≈â«·μà«—π∑.Ë’ ................................‡¥◊Õπ............................................æ.»......................

≈ß™Ë◊Õ.......................................................
(......................................................)
‡®â“æπ—°ß“π∑’Ë¥‘π

μ«— Õ¬“à ßÀ¡“¬‡≈¢ ¯ ÒÚÒ

(∑.¥. Òˆ)

∫π— ∑°÷ ¢Õâ μ°≈ߪ≈Õ¥¿“√–®”¬Õ¡

∑Ë’¥‘π
√–«“ß..................5..1..3..6...I..V....7..2..2.8..-..1.....................................μ”∫≈........................................................................
‡≈¢∑¥’Ë ‘π...............Ò................Àπâ“ ”√«®........Û...Ù..Ù...............Õ”‡¿Õ.......................................................................
‚©π¥À¡“¬‡≈¢∑.’Ë .............Ò..Û..ı.............................................®—ßÀ«—¥.......................................................................

∑’Ë«“à °“√.....................................................................

«π— ∑.Ë’ ...............‡¥Õ◊ π........................................æ.».....................

¢“â 懮“â .....................π..“..¬....°.......‡.®..â“..¢..Õ..ß..¿...“..√..¬..∑..√..æ—...¬..å .................................. ‡≈¢ª√–®”μ—«ª√–™“™π

.....................π..“..¬....¢.......‡.®..â“..¢..Õ..ß.. ...“..¡..¬..∑..√..—æ...¬..å..................................

Õ“¬.ÿ ..................ªï ‡™È◊Õ™“μ‘............................... —≠™“μ.‘ ..............................∫¥‘ “/¡“√¥“™Õ◊Ë ............................................................

Õ¬àŸ∑’Ë∫“â π/À¡∫Ÿà “â π......................................‡≈¢∑.’Ë .............μ√Õ°/´Õ¬.....................................∂ππ.................................À¡∑Ÿà Ë.’ .........

μ”∫≈/·¢«ß...............................Õ”‡¿Õ/‡¢μ...............................®—ßÀ«¥— ................................À¡“¬‡≈¢‚∑√»æ— ∑.å .............................

¢//Õ//ª//Ø//≠‘ //“/≥///μ//π//·/≈//–//„/À//â∂//âÕ//¬/§//”//μ/Õà//......‰.¥..â∑...”..∫..π—..∑...°÷ ..¢..âÕ..μ...°..≈..ß..μ...àÕ..‡.®..“â..æ...π..°—..ß..“..π..∑...Ë’¥..π‘.....................................................................................

¥//â«//¬//§//«/“/¡// //—μ//¬//å®/√//ß‘ / ¥ß— μàÕ‰ªπ’È :›
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. ..“..¡..¬...∑..√..æ—...¬..å..μ..“..¡...∫..—π...∑..°÷...¢..°â ..μ...°..≈...ß..©..∫...—∫...≈..ß..«..—π...∑...’Ë ......................‡..¥..◊Õ...π..................................................æ.....»............................π...—Èπ....∫..¥— ...π..È’ ..¢..“â ..æ..‡..®..â“..∑..Èß—... ..Õ...ß..Ω..“É ..¬...‰.¥..μâ...°..≈...ß..¬..‘π...¬..Õ...¡..........
.„.À..â∑...’¥Ë..‘π...‡.©...æ..“..–.. ...«à..π..∑...’·Ë..∫...àß..·..¬...°..Õ...Õ..°..¡...“..‡.ª...πì ..‚..©..π...¥..„..À..¡...à‡.≈..¢...∑..’Ë................ˆ.....Ú......Û.....Û....................Õ..”..‡..¿..Õ........................................ª...≈..Õ...¥..¿...“..√..–..®..”..¬...Õ..¡...‰.¥...â ....................................
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......................∫...—π..∑...÷°..¢..Õâ...μ..°...≈..ß..π...È’∑..”..‰..«..â .Ò....©...∫..—∫....‡..°..Á∫...‰.«..â..≥..... ..”..π..°—...ß..“..π..∑...¥Ë’ ..‘π....∑...Èß— .. ..Õ...ß..Ω..“É..¬...‰.¥...âμ..√..«..®...¥..Ÿ∫...—π..∑...÷°..¢..Õâ...μ..°...≈..ß..·...≈..–..‡..¢..â“..„.®...¢..âÕ..§...«..“..¡..μ...≈..Õ...¥.
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............................................................................................≈..ß...™..◊ËÕ...........................................................π......“....¬.........¢......................................................‡.®..“â..¢...Õ..ß.. ...“..¡..¬...∑..√..æ—...¬..å...................
............................................................................................≈..ß...™..◊ËÕ....................................................................................................................................æ...¬..“..π...........................................
............................................................................................≈..ß...™..Ë◊Õ.....................................................................................................................................æ...¬..“..π...........................................
.............................∫...—π..∑...°÷ ..¢..Õâ...μ..°...≈..ß..π...È’‰..¥..∑â...”..μ..Õà...À..π...“â ......................................................................................................................................
............................................................................................≈..ß...™..Ë◊Õ.....................................................................................................................................‡.®..“â..æ...π...°— ..ß..“..π..∑...¥’Ë..π‘..........................
..........................................................................................................ª..√..–..∑...∫—..μ...√..“..μ...”.·...À..π...ßà ..‡.ª...πì.. ...”..§..—≠..........................................................

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μ—«Õ¬à“ßÀ¡“¬‡≈¢ ¯ ÒÚÚ

 “√∫—≠®¥∑–‡∫¬’ π

(√“¬°“√®¥∑–‡∫’¬π·ª≈߇¥‘¡‚©π¥∑’ˇªπì ¿“√¬∑√æ— ¬)å

®¥∑–‡∫’¬π ª√–‡¿∑°“√ ºŸâ„À â ≠— ≠“ ºŸâ√—∫ —≠≠“ ‡π◊ÈÕ∑Ë’¥‘π ‡π◊ÈÕ∑’Ë¥‘π √–«“ß ‡®â“æπ—°ß“π∑’Ë¥‘π
«π— ‡¥◊Õπ ªï ®¥∑–‡∫’¬π μ“¡ —≠≠“ §ß‡À≈Õ◊ ‡≈¢∑Ë’¥‘π ≈ß≈“¬¡Õ◊ ™Õ◊Ë
‚©π¥∑Ë’¥π‘ „À¡à ª√–∑∫— μ√“
«—π∑’.Ë ................. ¿“√–®”¬Õ¡ ‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
‡¥Õ◊ π................ «“ «“
æ.». ..................
∑¥Ë’ ‘π·ª≈ßπμ’È °Õ¬Ÿà„π∫—ߧ—∫¿“√–®”¬Õ¡‡√ÕË◊ ß∑“߇¥‘π ∑“ß√∂¬πμå ‰øøÑ“ ª√–ª“ (≈ß™◊ÕË ) 𓬠 .
μ≈Õ¥®π “∏“√≥ªŸ ‚¿§μà“ßÊ ¢Õß∑’¥Ë ‘π‚©π¥‡≈¢∑’Ë ÒÛıÛ Õ”‡¿Õ..............................
®ß— À«—¥.......................μ“¡∫π— ∑°÷ ¢Õâ μ°≈ß©∫—∫≈ß«π— ∑’.Ë ........‡¥Õ◊ π...................æ.».............

«π— ∑.Ë’ ............... ·∫àß·¬°„ππ“¡‡¥¡‘ 𓬠°. 𓬠°. Ò › › Ò › › 5136IV 7228›1 (≈ß™Ë◊Õ).........................

‡¥◊Õπ............. (ª≈Õ¥¿“√–®”¬Õ¡) ∑Ë¥’ π‘ ·ª≈ß∑Ë·’ ¬°‰ªπÈ’æπâ ®“°¿“√–®”¬Õ¡ Ò
æ.»................ μ“¡∫π— ∑÷°¢Õâ μ°≈ߪ≈Õ¥¿“√–®”¬Õ¡ ˆÚÛÛ
©∫∫— ≈ß«π— ∑.’Ë .........‡¥◊Õπ....................æ.»............

 à«π·ª≈ߧ߇À≈Õ◊ ¿“√–®”¬Õ¡¬—ߧߡՒ ¬Ÿà
μ“¡∫π— ∑°÷ ¢âÕμ°≈ß ©∫—∫≈ß«—π∑.Ë’ ..................
‡¥◊Õπ............................æ.». .............

À¡“¬‡Àμÿ ∑’Ë¥‘π·ª≈ß·¬°ª≈Õ¥¿“√–®”¬Õ¡‰¡μà Õâ ߬°√“¬°“√®¥·®ßâ ·μàÕ¬à“ß„¥

μ«— Õ¬“à ßÀ¡“¬‡≈¢ ˘ ÒÚÛ

(∑.¥. ˘)

§”¢Õ..·...∫..ßà ..·..¬...°..„.π...“.¡...‡.¥..‘¡....(.§...√..Õ..∫...¿..“..√..–..®..”..¬..Õ..¡...)

©∫—∫∑.Ë’ ......................................

∑Ë’¥‘π
√–«“ß..................5..1..3..6...I.V.....7.2..2..8..-.1.......................................μ”∫≈.........................................................................................
‡≈¢∑.Ë’ ..................Ò..................................Àπâ“ ”√«®..................Û..Ù...Ù...........................Õ”‡¿Õ..................................................
‚©π¥À¡“¬‡≈¢∑Ë.’ ............Ò...Û..ı..............................................®—ßÀ«—¥.......................................................................................

«π— ∑’.Ë ...............‡¥◊Õπ.....................................æ.». ......................

¢“â 懮“â ...........................π..“..¬....°................................................................. ‡≈¢ª√–®”μ—«ª√–™“™π

Õ“¬.ÿ ..............ªï ‡™◊ÈÕ™“μ‘............................. —≠™“μ.‘ ............................∫¥‘ “/¡“√¥“™Ë◊Õ.....................................................................

Õ¬àŸ∑Ë∫’ â“π/À¡Ÿà∫â“π...............................................‡≈¢∑.’Ë ...................μ√Õ°/´Õ¬............................∂ππ..........................À¡à∑Ÿ .’Ë ..........

μ”∫≈/·¢«ß..................................Õ”‡¿Õ/‡¢μ..................................®ß— À«¥— ..................................À¡“¬‡≈¢‚∑√»æ— ∑.å ......................

¢Õ¬Ëπ◊ §”¢ÕμÕà ‡®“â æπ°— ß“π∑’¥Ë π‘ ®ß— À«¥— ....................................................¥«â ¬§«“¡ μ— ¬®å √‘ß«“à :-

¢Õâ Ò. ¥â«¬.....¢..“â..æ..‡..®..“â ..¡..™’ ..◊ËÕ..‡..ª..ìπ..º...Ÿ∂â ..◊Õ..°...√.√..¡... ..∑‘..∏...‘∑Ï ..Ë¥’..‘π...·..ª..≈...ß..‡.§..√..ÕË◊...ß..À..¡..“..¬..¢...“â .ß..∫...π..π...È’ .‚.¥...¬..À..π...ß— .. ..◊Õ..π...¢È’ ..â“..æ..‡.®..â“..¡...§’ ..«..“..¡..ª...√..–.. ..ß..§..å...
®...–..·..∫..àß..·...¬..°..„.π...π..“..¡..‡.¥...‘¡..∑...Ë’¥..‘π..·...ª..≈..ß..π...ÕÈ’ ..Õ..°..®...“.°...°..—π..¥...ß— ..π..È’ .·...∫..àß..∑..“..ß..∑...‘»..‡.À...π..Õ◊ ....Ò...·...ª..≈..ß....·..∫...àß..∑..“..ß..∑..‘»..μ...–..«..—π..Õ...Õ..°....Ò...·...ª..≈..ß....√..«..¡...Ú....·...ª..≈..ß..........
‚..¥..¬..„..À..·â..ª...≈..ß..·..¬...°..∑..“..ß..∑..‘»...‡.À..π...Õ◊ ..‰.¡...à¡..’¿...“.√..–..®...”.¬...Õ..¡..μ...“.¡...∫..—π...∑..°÷ ..¢..Õâ...μ..°..≈...ß..®..¥..∑..–..‡..∫..¬’..π...¿..“..√..–..®..”..¬..Õ...¡..∫..“..ß.. ..«à..π....©..∫...∫— ..≈...ß..«..π— ..∑...’Ë...............‡.¥...◊Õ..π...................................
æ.....»................................................·..μ..–..μ...Õâ ..ß.... ..à«..π..·..ª...≈..ß..·..¬...°..∑..“..ß..∑...»‘ ..μ..–..«..—π...Õ..Õ..°...·..≈..–..·..ª...≈..ß..§..ß..‡..À..≈..◊Õ....¬..ß—..§...ß..¡..’¿...“.√..–...®..”.¬...Õ..¡..∫...“..ß.. ..«à ..π..μ...“.¡...∫..π—..∑...÷°..¢..Õâ...μ..°..≈..ß........
©...∫..—∫...≈..ß..«..π— ..∑....’Ë ..............‡..¥..Õ◊ ..π..............................æ.....»......................§..√..Õ..∫...μ..‘¥..Õ...¬..Ÿà.´...ßË÷ ..¢..â“..æ..‡.®...“â ...®..–..‰.¥...πâ ..”..™..“à..ß..·..º..π...∑..’∑Ë..”..°...“.√..√..ß—..«..¥—...ª..°í..À...≈..—°..‡..¢..μ..„.À...‡â .ª..ìπ...°..“..√..·..π..πà...Õ..π..μ...Õà ..‰.ª....

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¢âÕ Ú. ©–ππÈ— ¢Õ„À‡â ®“â æπ°— ß“π∑¥’Ë π‘ ..‰.¥...â‚.ª..√..¥...¥..”..‡.π...π‘ ..°..“..√..„.À...â·..°..¢à..“â..œ....μ..“..¡..§...«..“..¡..ª..√..–.. ...ß..§..åμ..Õà...‰.ª...¥..â«..¬....·..≈..–..¢..â“..œ....¢..Õ..√..—∫...√..Õ..ß..«..“à..

.∂..â“..∑..’¥Ë..π‘...√..“.¬...π..È¡’..‡’..¢..μ..§...≈..“..¥..‡.§...≈..Õ◊Ë..π...¥..«â..¬..ª...√..–..°..“..√..„.¥...Ê...¢..“â..œ....¬..Õ..¡...„.À..‡â.®...“â .æ...π..°—..ß..“..π...·..°..â‰..¢..„.À...‡â .ª..ìπ...°..“..√..∂..°Ÿ ..μ..âÕ...ß...¢..â“..æ...‡.®..“â..¬..Õ...¡..‡. ..’¬...§..à“..∏..√..√..¡..‡..π..’¬..¡.......
.μ..“..¡..√..–..‡.∫...¬’ ..∫....................................................................................................................................................................................

.....................................................................................................................................................................................................

.......................π..“..¬....°.......................... ºŸâ¢Õ
........................................................ 欓π
........................................................ 欓π

ÒÚÙ

μ—«Õ¬à“ßÀ¡“¬‡≈¢ ˘ (∑.¥. Ò)

∑∫’Ë “â π

∑Ë ’ «π/‰√à

∑’Ëπ“

∑Ë.’ .............

§”¢Õ®¥∑–‡∫¬’ π ‘∑∏·‘ ≈–πμ‘ ‘°√√¡ πÕ°‡¢μ
·≈–°“√ Õ∫ «π ‘∑∏‘„π∑¥’Ë π‘ ª√–‡¿∑...·...∫..ßà..·..¬...°..„.π...π..“..¡..‡.¥...¡‘ ............... „π‡¢μ

μ”·Àπàß∑Ë’¥‘π ·¬° Ò

∑’Ë ‘¥π·ª≈ß∑’Ë·¬°‰ªπÈ’‰ à¡¡’¿“√–®”¬Õ¡ μ“¡∫—π∑÷° â¢Õμ°≈ß®¥∑–‡∫’¬π¿“√–®”¬Õ¡∫“ß à«π ©∫—∫≈ß«—π∑Ë’.........‡¥◊Õπ....................æ.».............·μ–μâÕß·μàÕ à¬“ß„¥ √–«“ß.................5..1..3..6...I.V....7..2..2..8..-.1................................................. μ”∫≈.........................................................................................
‡®â“æπ—°ß“π ’Ë∑¥‘π
‡≈¢∑Ë¥’ π‘ .......................Ò.............................................................. Õ”‡¿Õ........................................................................................

Àπâ“ ”√«®..................Û...Ù..Ù...........................................................®ß— À«¥— ........................................................................................

‚©π¥∑’Ë¥‘π
‡≈¢∑Ë.’ ....................Ò..Û..ı...................‡≈¡à ........................................Àπâ“....................................

®”π«π∑’Ë¥π‘ ...............Ò..ı..................‰√à..............›...................ß“π...............›....................μ“√“ß«“

Ò. ¢“â 懮⓺⟡’π“¡μàÕ‰ªπ’È ¡’§«“¡ª√– ß§¢å Õ®¥∑–‡∫¬’ π ‘∑∏·‘ ≈–π‘μ°‘ √√¡‡°’¬Ë «°—∫Õ ß— À“√¡‘ ∑√æ— ¬∑å Ë°’ ≈à“«¢â“ß∫ππ’È ·≈–

‰¥ªâ Ø‘≠“≥μπ·≈â« ¢Õ„Àâ∂Õâ ¬§”¥â«¬§«“¡ μ— ¬å®√ß‘ ∂â“¢“â 懮“â „Àâ∂Õâ ¬§”‰¡‡à ªì𧫓¡®√ß‘ „Àâ„™∂â âÕ¬§”π¬È’ —π¢â“懮“â „π∑“ߧ¥Õ’ “≠“‰¥â

Ú. ¢â“懮â“..............π..“..¬....°............................ ‡≈¢ª√–®”μ—«ª√–™“™π ºŸâ...∂..◊Õ..°...√..√..¡.. ..‘∑...∏..‘Ï ...............

.................................................

Õ“¬.ÿ .................................ªï  —≠™“μ‘.........................................∫¥‘ “/¡“√¥“™◊ËÕ.............................................................................

‚ ¥ À¡“â ¬ §à Ÿ ¡√ ™Ë◊Õ..........................................................................................

Õ¬àŸ∑’∫Ë “â π/À¡Ÿà∫“â π..........................‡≈¢∑.Ë’ ...............μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡Ÿ∑à .’Ë .............

μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®—ßÀ«¥— .................................À¡“¬‡≈¢‚∑√»—æ∑.å ....................

Û. ¢“â 懮â“................π..“..¬....°.......................... ‡≈¢ª√–®”μ—«ª√–™“™π º.⟠..∂..Õ◊...°..√..√..¡.. ...∑‘ ..∏..Ï‘...............

................................................
Õ“¬.ÿ .................................ªï  —≠™“μ‘.........................................∫¥‘ “/¡“√¥“™ËÕ◊ .............................................................................

‚ ¥ À¡“â ¬ § Ÿà ¡√ ™◊ËÕ....................................................... ≠— ™“μ.‘ ......................
Õ¬àŸ∑Ë’∫“â π/À¡à∫Ÿ â“π..........................‡≈¢∑Ë’................μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡Ÿà∑’.Ë .............
μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«—¥.................................À¡“¬‡≈¢‚∑√»—æ∑å.....................

Ù. ¢“â 懮“â ¢Õ· ¥ß√“§“∑√æ— ¬å∑¢Ë’ Õ∑”π‘μ°‘ √√¡π‡È’ ªìπ‡ßπ‘ .............................›............................∫“∑.........›........... μ“ߧå
ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à

(Ò) ¢â“懮“â ‰¡à‰¥â√∫— ‚Õπ·∑πÀ√Õ◊ ‡æÕË◊ ª√–‚¬™πå·°à∫ÿ§§≈μ“à ߥ⓫
(Ú) √“§“∑√æ— ¬∑å ·Ë’  ¥ß‰«â„π Ù. ‡ªπì √“§“∑’·Ë ∑®â √ß‘
(Û) .....................................................................................................................................................................
(Ù) .....................................................................................................................................................................
(ı) .....................................................................................................................................................................

«π— ∑.’Ë ...........‡¥Õ◊ π..............................æ.»..................
≈ß™ËÕ◊ .....................π..“..¬...°...........................ºŸâ¢Õ ∂Õ◊ °√√¡ ‘∑∏Ï‘
≈ß™ËÕ◊ .....................π..“..¬...°..........................ºâŸ¢Õ ∂Õ◊ °√√¡ ‘∑∏Ï‘
≈ß™◊ËÕ......................................................º âŸ Õ∫ «π

(......................................................)
 ”À√—∫æπ—°ß“π‡®â“Àπ“â ∑’Ë
Ò) √“§“ª√–‡¡π‘ ∑ÿπ∑√—æ¬.å ....................................................................................................∫“∑........................................ μ“ߧå
Ú) ‚©π¥∑’Ë¥‘π„À¡√à –«“ß......5..1..3..6...I.V.....7.2..2..8..-.1...............‡≈¢∑Ë’¥π‘ .................Ò..............................Àπâ“ ”√«®.........Û..Ù..Ù............................
‚©π¥∑’¥Ë ‘π‡≈¢∑.Ë’ ....................ˆ..Ú..Û...Û.......................‡≈¡à ........................ˆ..Û............................Àπâ“..................Û..Û..............................
®”π«π∑¥Ë’ π‘ ..............................ı........................‰√.à .............................›...................ß“π..............................›....................μ“√“ß«“
§ß‡À≈Õ◊ .................................Ò..........................‰√.à .............................›...................ß“π..............................›....................μ“√“ß«“
Û) ‰¥®â ¥∑–‡∫’¬π·≈«â ·μà«π— ∑Ë’.................................‡¥Õ◊ π............................................æ.»......................

≈ß™Õ◊Ë .......................................................
(......................................................)
‡®â“æπ—°ß“π∑Ë’¥‘π

μ—«Õ¬à“ßÀ¡“¬‡≈¢ ˘ ÒÚı

(∑.¥. Ò)
∑∫Ë’ “â π

∑ Ë’ «π/‰√à

∑’Ëπ“

∑’Ë..............

§”¢Õ®¥∑–‡∫¬’ π ‘∑∏·‘ ≈–πμ‘ ‘°√√¡ πÕ°‡¢μ
„π‡¢μ

∑Ë’ ‘¥π·ª≈ß∑’Ë·¬°‰ªπ’È·≈–·ª≈ߧ߇À≈◊Õ¬—ß¡’¿“√–®”¬Õ¡μ“¡∫—π∑÷° â¢Õμ°≈ß®¥∑–‡∫’¬π¿“√–®”¬Õ¡∫“ß à«π ©∫—∫≈ß«—π∑’Ë.........‡ ◊¥Õπ....................æ.».............§√Õ∫μ‘¥Õ¬Ÿà ·≈–°“√ Õ∫ «π ∑‘ ∏‘„π∑Ë¥’ ‘π ª√–‡¿∑...·...∫..ßà..·..¬...°..„.π...π..“..¡..‡.¥...¡‘ ............... ·¬° Ú
‡®â“æ —π°ß“π Ë’∑ ‘¥π
μ”·Àπàß∑’Ë¥‘π (§√Õ∫¿“√–®”¬Õ¡∫“ß à«π) ·≈–·ª≈ߧ߇À≈Õ◊

√–«“ß.................5..1..3..6...I.V....7..2..2..8..-.1................................................. μ”∫≈.........................................................................................

‡≈¢∑’¥Ë π‘ .......................Ò.............................................................. Õ”‡¿Õ........................................................................................

Àπâ“ ”√«®..................Û...Ù..Ù...........................................................®ß— À«—¥........................................................................................

‚©π¥∑Ë¥’ ‘π
‡≈¢∑Ë’.....................Ò..Û...ı..................‡≈à¡........................................Àπ“â ....................................

®”π«π∑¥Ë’ ‘π...............Ò..ı..................‰√.à .............›...................ß“π...............›....................μ“√“ß«“

Ò. ¢“â æ‡®â“ºâŸ¡π’ “¡μÕà ‰ªπÈ’ ¡§’ «“¡ª√– ß§å¢Õ®¥∑–‡∫¬’ π ∑‘ ∏‘·≈–πμ‘ °‘ √√¡‡°’ˬ«°—∫Õ —ßÀ“√‘¡∑√—æ¬∑å °’Ë ≈à“«¢“â ß∫ππÈ’ ·≈–

‰¥ªâ Ø‘≠“≥μπ·≈â« ¢Õ„À∂â âÕ¬§”¥«â ¬§«“¡ μ— ¬®å √‘ß ∂â“¢“â 懮“â „Àâ∂âÕ¬§”‰¡‡à ªπì §«“¡®√‘ß„Àâ„™∂â Õâ ¬§”πȬ’ —π¢â“懮Ⓞπ∑“ߧ¥Õ’ “≠“‰¥â

Ú. ¢â“懮â“..............π..“..¬...°............................. ‡≈¢ª√–®”μ—«ª√–™“™π ºŸâ...∂..◊Õ..°...√..√..¡.. ..‘∑...∏..Ï‘ ...............

.................................................

Õ“¬.ÿ .................................ªï  —≠™“μ‘.........................................∫¥‘ “/¡“√¥“™◊ÕË .............................................................................

‚ ¥ À¡“â ¬ § Ÿà ¡√ ™◊ËÕ..........................................................................................

Õ¬Ÿà∑∫’Ë â“π/À¡à∫Ÿ â“π..........................‡≈¢∑’Ë................μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡à∑Ÿ Ë’..............

μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«¥— .................................À¡“¬‡≈¢‚∑√»—æ∑å.....................

Û. ¢â“懮â“................π..“..¬....°.......................... ‡≈¢ª√–®”μ—«ª√–™“™π ºâ.Ÿ ..∂..Õ◊...°..√..√..¡.. ...∑‘ ..∏..‘Ï...............

................................................
Õ“¬.ÿ .................................ªï  —≠™“μ‘.........................................∫‘¥“/¡“√¥“™Ë◊Õ.............................................................................

‚ ¥ À¡“â ¬ §àŸ ¡√ ™ËÕ◊ ....................................................... —≠™“μ.‘ ......................
Õ¬à∑Ÿ Ë’∫“â π/À¡à∫Ÿ “â π..........................‡≈¢∑.Ë’ ...............μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡Ÿ∑à .Ë’ .............
μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«—¥.................................À¡“¬‡≈¢‚∑√»—æ∑.å ....................

Ù. ¢â“懮“â ¢Õ· ¥ß√“§“∑√æ— ¬∑å ¢Ë’ Õ∑”πμ‘ ‘°√√¡π‡È’ ªìπ‡ßπ‘ .............................›............................∫“∑.........›........... μ“ߧå
ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à

(Ò) ¢â“懮“â ‰¡à‰¥√â —∫‚Õπ·∑πÀ√Õ◊ ‡æËÕ◊ ª√–‚¬™πå·°à∫§ÿ §≈μ“à ߥ⓫
(Ú) √“§“∑√æ— ¬∑å ’Ë· ¥ß‰«â„π Ù. ‡ªπì √“§“∑’·Ë ∑®â √‘ß
(Û) .·..∫..ßà..·...¬..°..„.π...π..“..¡..‡..¥..‘¡....(.§..√..Õ...∫..¿..“..√..–..®..”..¬...Õ..¡..)...μ..“..¡..§...”..¢..Õ..≈..ß..«..π—...∑..Ë’........................‡..¥..Õ◊..π................................................æ....»................................................
(Ù) .....................................................................................................................................................................
(ı) .....................................................................................................................................................................

«π— ∑.’Ë ...........‡¥Õ◊ π..............................æ.»..................
≈ß™ÕË◊ .....................π..“..¬...°...........................ºŸâ¢Õ ∂Õ◊ °√√¡ ‘∑∏‘Ï
≈ß™Õ◊Ë .....................π..“..¬...°..........................ºâŸ¢Õ ∂Õ◊ °√√¡ ‘∑∏Ï‘
≈ß™◊ËÕ......................................................º Ÿâ Õ∫ «π

(......................................................)

 ”À√—∫æπ—°ß“π‡®â“Àπ“â ∑Ë’
Ò) √“§“ª√–‡¡‘π∑πÿ ∑√æ— ¬å.....................................................................................................∫“∑........................................ μ“ߧå
Ú) ‚©π¥∑¥Ë’ π‘ „À¡à√–«“ß......5..1..3..6...I.V.....7.2..2..8..-.1...............‡≈¢∑¥Ë’ ‘π.................Ò.....Ò.........................Àπ“â  ”√«®.........Û..Ù..ˆ............................

‚©π¥∑Ë¥’ π‘ ‡≈¢∑.Ë’ ....................ˆ..Ú..Û...Ù.......................‡≈¡à ........................ˆ..Û............................Àπâ“..................Û..Ù..............................
®”π«π∑¥Ë’ π‘ ............................ı..........................‰√.à .............................›...................ß“π..............................›....................μ“√“ß«“
§ß‡À≈Õ◊ .................................ı..........................‰√.à .............................›...................ß“π..............................›....................μ“√“ß«“
Û) ‰¥â®¥∑–‡∫’¬π·≈«â ·μ«à π— ∑’.Ë ................................‡¥◊Õπ............................................æ.»......................

≈ß™ËÕ◊ .......................................................
(......................................................)
‡®â“æπ—°ß“π∑Ë’¥‘π

μ—«Õ¬à“ßÀ¡“¬‡≈¢ ˘ ÒÚˆ

 “√∫—≠®¥∑–‡∫¬’ π (√“¬°“√®¥∑–‡∫¬’ π·ª≈߇¥‘¡‚©π¥‡≈¢∑’Ë ÒÛı)

®¥∑–‡∫’¬π ª√–‡¿∑°“√ ºâŸ„À â ≠— ≠“ ºŸâ√—∫ —≠≠“ ‡πÈ◊Õ∑Ë’¥‘π ‡πÈ◊Õ∑’Ë¥‘π √–«“ß ‡®â“æπ—°ß“π∑’Ë¥‘π
«π— ‡¥◊Õπ ªï ®¥∑–‡∫¬’ π μ“¡ ≠— ≠“ §ß‡À≈Õ◊ ‡≈¢∑Ë’¥‘π ≈ß≈“¬¡Õ◊ ™Õ◊Ë
‚©π¥∑¥Ë’ π‘ „À¡à ª√–∑∫— μ√“
‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
«“ «“

«π— ∑.Ë’ ................. ¿“√–®”¬Õ¡∫“ß à«π ∑’Ë¥‘π·ª≈ßπ’Èμ°Õ¬Ÿà„π∫—ߧ∫— ¿“√–®”¬Õ¡‡√Ë◊Õß∑“߇¥π‘ ∑“ß√∂¬πμå ‰øø“Ñ ª√–ª“ (≈ß™ÕË◊ ) 𓬠 .

‡¥◊Õπ................ μ≈Õ¥®π “∏“√≥ªŸ ‚¿§μ“à ßÊ ¢Õß∑Ë¥’ π‘ ‚©π¥‡≈¢∑Ë’ ÒÛıÛ Õ”‡¿Õ............................ 5136IV 7228›1 (≈ß™ÕË◊ ).........................
æ.». .................. ®—ßÀ«—¥.......................μ“¡∫π— ∑÷°¢âÕμ°≈ß©∫∫— ≈ß«π— ∑Ë.’ ......‡¥Õ◊ π......................æ.».......... Ò
ˆÚÛÛ
«—π∑’.Ë ............... ·∫àß·¬°„ππ“¡‡¥¡‘ 𓬠°. 𓬠°. ı › › Ò › ›

‡¥Õ◊ π............. (§√Õ∫¿“√–®”¬Õ¡) ∑¥’Ë π‘ ·ª≈ß∑·Ë’ ¬°‰ªπ’ȉ¡¡à ¿’ “√–®”¬Õ¡μ“¡

æ.»................ ∫π— ∑°÷ ¢Õâ μ°≈ß®¥∑–‡∫¬’ π¿“√–®”¬Õ¡
∫“ß «à π ©∫∫— ≈ß«π— ∑.’Ë ........‡¥Õ◊ π..................

æ.»...........·μ–μÕâ ß·μÕà ¬“à ß„¥

ı››ı›› 5136IV 7228›1 (≈ß™ËÕ◊ ).........................
∑¥’Ë π‘ ·ª≈ß∑·Ë’ ¬°‰ªπ·È’ ≈–·ª≈ߧ߇À≈Õ◊ ÒÒ
¿“√–®”¬Õ¡¬ß— ¡¿’ “√–®”¬Õ¡μ“¡∫π— ∑°÷ ˆÚÛÙ
¢Õâ μ°≈ß®¥∑–‡∫¬’ π¿“√–®”¬Õ¡∫“ß «à π
©∫∫— ≈ß«π— ∑.’Ë ........‡¥Õ◊ π..................æ.»...........
§√Õ∫쥑 Õ¬Ÿà

À¡“¬‡Àμÿ ∑¥’Ë π‘ ·ª≈ß·¬°‡ªπì ‚©π¥‡≈¢∑Ë’ ˆÚÛÛ ‰¡¡à ¿’ “√–®”¬Õ¡·μ–μÕâ ߉¡àμÕâ ߬°√“¬°“√®¥·®âß·μàÕ¬à“ß„¥

μ—«Õ¬à“ßÀ¡“¬‡≈¢ ˘

 “√∫≠— ®¥∑–‡∫’¬π

(√“¬°“√®¥·®ßâ ∑¥’Ë ‘π·ª≈ß∑’Ë·¬°‰ª„À¡à ‚©π¥‡≈¢∑Ë’ ˆÚÛÙ Õ”‡¿Õ........)

®¥∑–‡∫’¬π ª√–‡¿∑°“√ ºŸâ„À â ≠— ≠“ ºâŸ√—∫ —≠≠“ ‡πÈ◊Õ∑’Ë¥‘π ‡π◊ÈÕ∑’Ë¥‘π √–«“ß ‡®â“æπ—°ß“π∑Ë’¥‘π
«—𠇥Õ◊ π ªï ®¥∑–‡∫’¬π μ“¡ —≠≠“ §ß‡À≈Õ◊ ‡≈¢∑’Ë¥‘π ≈ß≈“¬¡Õ◊ ™ÕË◊
‚©π¥∑Ë¥’ π‘ „À¡à ª√–∑∫— μ√“
‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
«“ «“

«π— ∑Ë.’ ................. ¿“√–®”¬Õ¡∫“ß «à π ∑’Ë¥π‘ ·ª≈ßπÈμ’ °Õ¬Ÿà„π∫ß— §∫— ¿“√–®”¬Õ¡‡√Ë◊Õß∑“߇¥π‘ ∑“ß√∂¬πμå ‰øøÑ“ ª√–ª“ (≈ß™Ë◊Õ) 𓬠 .
«π— ∑Ë.’ ............................
‡¥◊Õπ................ (§√Õ∫¿“√–®”¬Õ¡) μ≈Õ¥®π “∏“√≥ªŸ ‚¿§μ“à ßÊ ¢Õß∑’Ë¥‘π‚©π¥∑’Ë ÒÛıÛ Õ”‡¿Õ....................................... ‡¥◊Õπ..........................
æ.». .............................
æ.». .................. ®—ßÀ«¥— ........................μ“¡∫π— ∑°÷ ¢âÕμ°≈ß©∫∫— ≈ß«—π∑’Ë.........‡¥Õ◊ π...................æ.»............. (≈ß™Õ◊Ë ).......................

ÒÚ˜

ÒÚ¯

μ—«Õ¬“à ßÀ¡“¬‡≈¢ Ò

(∑.¥. ˘)

§”¢Õ..·...∫..àß..·..¬...°..„.π..“..¡...‡.¥..¡‘....(.§...√..Õ..∫..›..ª...≈..Õ..¥...¿..“..√..–..®”¬Õ¡)

©∫∫— ∑.’Ë ......................................

∑’Ë¥‘π
√–«“ß..................5..1..3..6...I..V....7.2..2..8..-.1.......................................μ”∫≈.........................................................................................
‡≈¢∑Ë’...................Ò..................................Àπâ“ ”√«®..................Û..Ù...Ù...........................Õ”‡¿Õ..................................................
‚©π¥À¡“¬‡≈¢∑Ë.’ ............Ò...Û..ı..............................................®—ßÀ«¥— .......................................................................................

«—π∑.Ë’ ...............‡¥Õ◊ π.....................................æ.». ......................

¢â“懮â“...........................π..“..¬....°................................................................. ‡≈¢ª√–®”μ—«ª√–™“™π

Õ“¬ÿ...............ªï ‡™◊ÈÕ™“μ‘............................. —≠™“μ.‘ ............................∫‘¥“/¡“√¥“™◊ÕË .....................................................................

Õ¬à∑Ÿ ’∫Ë “â π/À¡àŸ∫â“π...............................................‡≈¢∑’Ë....................μ√Õ°/´Õ¬............................∂ππ..........................À¡Ÿà∑’Ë...........

μ”∫≈/·¢«ß..................................Õ”‡¿Õ/‡¢μ..................................®ß— À«¥— ..................................À¡“¬‡≈¢‚∑√»æ— ∑.å ......................

¢Õ¬Ëπ◊ §”¢ÕμÕà ‡®“â æπ—°ß“π∑¥’Ë ‘π®ß— À«—¥....................................................¥«â ¬§«“¡ —쬮å √ß‘ «à“ :-
¢Õâ Ò. ¥«â ¬...¢...“â .æ...‡.®..“â..¡..™’...ÕË◊ ..‡.ª...πì ..º..∂âŸ...◊Õ..°..√..√..¡.. ...∑‘ ..∏..∑‘Ï...Ë¥’ ..‘π..·...ª..≈..ß..‡..§..√..ËÕ◊ ..ß..À...¡..“..¬..¢..“â..ß..∫...π..π..’È..‚.¥..¬...À..π..ß—.. ...Õ◊ ..π..È¢’..“â..æ...‡.®..â“..¡..§’...«..“.¡...ª..√..–.. ..ß...§..å®..–..

·...∫..ßà..·..¬...°..„.π...π..“..¡..‡.¥...¡‘ ..∑..’¥Ë...‘π..·..ª...≈..ß..π..ÈÕ’...Õ..°..®..“..°..°...π— ..‡.ª...ìπ...Ú.....·..ª..≈...ß...‚.¥...¬..∑..¥Ë’...π‘ ..·..ª...≈..ß..·..¬..°...∑..’Ë..Ò...„..À..ªâ..≈...Õ..¥..®..“..°...¿..“..√..–..®..”..¬..Õ..¡.... ..”..À...√..—∫..·..ª...≈..ß..·..¬..°...∑..Ë’.Ú...
·...≈..–..·..ª...≈..ß..§..ß..‡..À..≈..◊Õ....¬..—ß..§...ß..μ..°...Õ..¬..Ÿà„..π..∫..ß—..§...∫— ..¿..“..√..–..®..”..¬...Õ..¡..¢..Õ...ß..∑..Ë¥’..π‘....‚..©..π..¥...‡.≈..¢..∑...Ë’ .Ò..Û...ı..Û....Õ..”..‡.¿..Õ................................®..—ß...À..«..—¥............................μ...“..¡..∫..—π...∑..°÷..¢..âÕ...μ..°..≈...ß.
©...∫..∫—...≈..ß..«..—π..∑...’.Ë ...................‡..¥..◊Õ..π.............................................æ....».............................´..Ë÷ß..¢..“â..æ..‡..®..â“..®..–..‰.¥..âπ...”...™..à“..ß..·..º...π..∑..∑Ë’...”..°..“..√..√..—ß..«..—¥..ª..°í...À..≈..°—..‡..¢..μ..„..À..â‡.ª...ìπ..°..“..√..·..π...àπ..Õ..π...μ..Õà..‰..ª............

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¢âÕ Ú. ©–ππ—È ¢Õ„À‡â ®“â æπ°— ß“π∑¥’Ë π‘ ..‰.¥..â.‚.ª..√..¥...¥..”..‡.π...‘π..°..“..√..„.À...·â ..°..à¢..â“..œ....μ..“..¡..§...«..“.¡...ª..√..–.. ...ß..§..åμ..àÕ...‰.ª...¥..â«..¬....·..≈..–..¢..“â..œ....¢..Õ..√..—∫...√..Õ..ß..«..“à..

∂...“â ..∑..Ë¥’ ..π‘...√..“.¬...π..’¡È..’‡..¢..μ..§...≈..“..¥..‡.§...≈..Õ◊Ë..π...¥..â«..¬..ª...√..–..°..“..√..„.¥...Ê...¢..â“..œ....¬..Õ..¡...„.À..â‡.®...“â .æ...π..°—..ß..“..π...·..°..â‰..¢..„.À...â‡.ª..πì...°..“..√..∂..Ÿ°..μ..âÕ...ß...¢..“â..æ...‡.®..“â..¬..Õ...¡..‡. ..’¬...§..“à..∏..√..√..¡..‡..π..¬’..¡.......
.μ..“..¡..√..–..‡.∫...¬’ ..∫....................................................................................................................................................................................

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.......................π..“..¬....°.......................... ºâŸ¢Õ
........................................................ 欓π
........................................................ 欓π

ÒÚ˘

μ—«Õ¬“à ßÀ¡“¬‡≈¢ Ò (∑.¥. Ò)

∑∫Ë’ “â π

∑’ Ë «π/‰√à

∑Ë’π“

∑.’Ë .............

μ”·Àπàß∑Ë’¥‘𠧔¢Õ®¥∑–‡∫¬’ π ‘∑∏·‘ ≈–πμ‘ ‘°√√¡ πÕ°‡¢μ
„π‡¢μ
·≈–°“√ Õ∫ «π ‘∑∏‘„π∑¥Ë’ ‘π ª√–‡¿∑...·...∫..ßà..·..¬...°..„.π...π..“..¡..‡.¥...¡‘ ...............
·¬° Ò
(§√Õ∫›ª≈Õ¥¿“√–®”¬Õ¡)

√–«“ß.................5..1..3..6...I.V....7..2..2..8..-.1.................................................μ”∫≈.........................................................................................

‡≈¢∑¥’Ë ‘π.......................Ò..............................................................Õ”‡¿Õ........................................................................................

Àπ“â  ”√«®..................Û...Ù..Ù...........................................................®—ßÀ«¥— ........................................................................................

∑’Ë¥‘π·ª≈ß∑Ë’·¬°‰ªπÈ’ âæπ®“°¿“√–®”¬Õ¡ μ“¡∫—π∑÷°¢âÕμ°≈ߪ≈Õ¥¿“√–®”¬Õ¡©∫—∫≈ß«—π∑’Ë.........‡ ◊¥Õπ....................æ.»............. ‚©π¥∑¥’Ë π‘
‡®â“æπ—°ß“π ’Ë∑¥‘π ‡≈¢∑’.Ë ....................Ò..Û..ı...................‡≈à¡............Ò..Ù..........................Àπ“â .....ı..Ò.............................

®”π«π∑’Ë¥‘π...............Û....................‰√à..............›...................ß“π...............›....................μ“√“ß«“

Ò. ¢â“懮⓺Ÿâ¡π’ “¡μàÕ‰ªπÈ’ ¡§’ «“¡ª√– ß§å¢Õ®¥∑–‡∫’¬π ‘∑∏‘·≈–π‘μ‘°√√¡‡°’¬Ë «°∫— Õ ß— À“√¡‘ ∑√æ— ¬∑å ’°Ë ≈“à «¢“â ß∫ππ’È ·≈–

‰¥âªØ≠‘ “≥μπ·≈â« ¢Õ„Àâ∂Õâ ¬§”¥«â ¬§«“¡ μ— ¬®å √ß‘ ∂“â ¢â“懮ⓄÀâ∂âÕ¬§”‰¡à‡ªì𧫓¡®√‘ß„Àâ„™â∂âÕ¬§”πÈ’¬π— ¢“â 懮“â „π∑“ߧ¥’Õ“≠“‰¥â

Ú. ¢â“懮â“..............π..“..¬....°............................ ‡≈¢ª√–®”μ—«ª√–™“™π ºâ.Ÿ ..∂..Õ◊..°...√..√..¡.. ..‘∑...∏..‘Ï ...............

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Õ“¬ÿ..................................ªï  ≠— ™“μ.‘ ........................................∫¥‘ “/¡“√¥“™Õ◊Ë .............................................................................

‚ ¥ À¡“â ¬ §à Ÿ ¡√ ™◊ÕË ..........................................................................................

Õ¬Ÿà∑Ë∫’ “â π/À¡∫Ÿà â“π..........................‡≈¢∑’Ë................μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡àŸ∑.Ë’ .............

μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«—¥.................................À¡“¬‡≈¢‚∑√»æ— ∑å.....................

Û. ¢“â 懮“â ................π..“..¬....°.......................... ‡≈¢ª√–®”μ—«ª√–™“™π º.Ÿâ ..∂...◊Õ..°..√..√..¡.. ...∑‘ ..∏..‘Ï...............

................................................
Õ“¬.ÿ .................................ªï  —≠™“μ.‘ ........................................∫‘¥“/¡“√¥“™Ë◊Õ.............................................................................

‚ ¥ À¡“â ¬ §à Ÿ ¡√ ™ÕË◊ ....................................................... —≠™“μ.‘ ......................
Õ¬Ÿà∑∫Ë’ â“π/À¡∫àŸ “â π..........................‡≈¢∑Ë’................μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡Ÿà∑.Ë’ .............
μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«¥— .................................À¡“¬‡≈¢‚∑√»—æ∑.å ....................

Ù. ¢“â 懮“â ¢Õ· ¥ß√“§“∑√—æ¬∑å ¢’Ë Õ∑”π‘μ°‘ √√¡π’ȇªìπ‡ß‘π.............................›............................∫“∑.........›........... μ“ߧå
ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à

(Ò) ¢“â 懮Ⓣ¡à‰¥√â —∫‚Õπ·∑πÀ√Õ◊ ‡æ◊ÕË ª√–‚¬™πå·°∫à ÿ§§≈μà“ߥ“â «
(Ú) √“§“∑√æ— ¬å∑·Ë’  ¥ß‰«â„π Ù. ‡ªπì √“§“∑’·Ë ∑â®√ß‘
(Û) .·..∫..ßà..·..¬...°..„.π...π..“..¡..‡.¥...¡‘ ....(.§..√..Õ...∫..›..ª..≈...Õ..¥..¿...“.√..–..®...”.¬...Õ..¡..)...μ..“..¡...§..”..¢..Õ..≈...ß..«..π— ..∑...Ë’ ..........‡.¥..Õ◊...π............................æ...»..........................
(Ù) .....................................................................................................................................................................
(ı) .....................................................................................................................................................................

«π— ∑.’Ë ...........‡¥Õ◊ π..............................æ.»..................
≈ß™ÕË◊ .....................π..“..¬...°...........................ºâŸ¢Õ ∂Õ◊ °√√¡ ∑‘ ∏‘Ï
≈ß™ÕË◊ .....................π..“..¬...°..........................ºâŸ¢Õ ∂◊Õ°√√¡ ‘∑∏‘Ï
≈ß™◊ËÕ......................................................º Ÿâ Õ∫ «π

(......................................................)
 ”À√—∫æπ—°ß“π‡®â“Àπ“â ∑Ë’
Ò) √“§“ª√–‡¡‘π∑ÿπ∑√æ— ¬.å ....................................................................................................∫“∑........................................ μ“ߧå
Ú) ‚©π¥∑¥Ë’ ‘π„À¡à√–«“ß......5..1..3..6...I..V....7..2.2..8..-..1..............‡≈¢∑Ë’¥‘π.................Ò.....Ò.........................Àπ“â  ”√«®.........Û..Ù..ı............................
‚©π¥∑¥’Ë ‘π‡≈¢∑’Ë.....................ˆ..Ú...Û..Û.......................‡≈¡à ........................ˆ..Û............................Àπâ“..................Û..Û..............................
®”π«π∑¥’Ë π‘ ............................Ò..........................‰√.à .............................›...................ß“π..............................›....................μ“√“ß«“
§ß‡À≈Õ◊ .................................Ú..........................‰√.à .............................›...................ß“π..............................›....................μ“√“ß«“
Û) ‰¥â®¥∑–‡∫’¬π·≈«â ·μ«à —π∑.Ë’ ................................‡¥Õ◊ π............................................æ.»......................

≈ß™◊ËÕ.......................................................
(......................................................)
‡®â“æπ—°ß“π∑Ë’¥‘π

ÒÛ

μ«— Õ¬“à ßÀ¡“¬‡≈¢ Ò (∑.¥. Ò)
∑∫’Ë “â π

∑ Ë’ «π/‰√à

∑’Ëπ“

∑.Ë’ .............

πÕ°‡¢μ

§”¢Õ®¥∑–‡∫¬’ π ∑‘ ∏‘·≈–π‘μ°‘ √√¡ „π‡¢μ

·≈–°“√ Õ∫ «π ∑‘ ∏‘„π∑¥’Ë π‘ ª√–‡¿∑...·...∫..ßà..·..¬...°..„.π...π..“..¡..‡.¥...¡‘ ............... ·¬° Ú ·≈–

μ”·Àπàß∑Ë’¥‘π (§√Õ∫›ª≈Õ¥¿“√–®”¬Õ¡) ·ª≈ߧ߇À≈◊Õ

Ë∑’ ‘¥π·ª≈ß Ë’∑·¬°‰ª ’πÈ·≈–·ª≈ߧ߇À ◊≈Õ¿“√–®”¬Õ¡ —¬ß§ß ’¡Õ¬Ÿàμ“¡ —∫π ÷∑°¢âÕμ°≈ß®¥∑–‡ ’∫¬π¿“√–®”¬Õ¡© —∫∫≈ß«—π ’Ë∑.........‡ ◊¥Õπ....................æ.»............. √–«“ß.................5..1..3..6...I.V....7..2..2..8..-.1.................................................μ”∫≈.........................................................................................
‡®â“æ —π°ß“π ’Ë∑¥‘π
‡≈¢∑’¥Ë ‘π.......................Ò..............................................................Õ”‡¿Õ........................................................................................

Àπ“â  ”√«®..................Û...Ù..Ù...........................................................®ß— À«¥— ........................................................................................

‚©π¥∑¥’Ë ‘π
‡≈¢∑.’Ë ....................Ò..Û..ı...................‡≈à¡............Ò..Ù..........................Àπ“â .....ı...............................

®”π«π∑Ë’¥‘π...............Ú....................‰√.à .............›...................ß“π...............›....................μ“√“ß«“

Ò. ¢â“懮⓺⟡’π“¡μàÕ‰ªπÈ’ ¡§’ «“¡ª√– ß§å¢Õ®¥∑–‡∫¬’ π ∑‘ ∏‘·≈–πμ‘ °‘ √√¡‡°’¬Ë «°∫— Õ ß— À“√¡‘ ∑√—æ¬å∑°’Ë ≈à“«¢“â ß∫ππ’È ·≈–

‰¥ªâ Ø≠‘ “≥μπ·≈«â ¢Õ„À∂â Õâ ¬§”¥«â ¬§«“¡ μ— ¬®å √‘ß ∂â“¢“â 懮ⓄÀâ∂âÕ¬§”‰¡‡à ªπì §«“¡®√ß‘ „Àâ„™â∂âÕ¬§”π¬È’ π— ¢â“懮“â „π∑“ߧ¥Õ’ “≠“‰¥â

Ú. ¢â“懮“â ..............π..“..¬....°............................ ‡≈¢ª√–®”μ—«ª√–™“™π º.⟠..∂..Õ◊..°...√..√..¡.. ..∑‘...∏..‘Ï ...............

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Õ“¬.ÿ .................................ªï  —≠™“μ‘.........................................∫‘¥“/¡“√¥“™Ë◊Õ.............................................................................

‚ ¥ À¡“â ¬ §Ÿ à ¡√ ™◊ÕË ..........................................................................................

Õ¬àŸ∑’Ë∫â“π/À¡àŸ∫â“π..........................‡≈¢∑Ë’................μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡Ÿà∑’.Ë .............

μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«¥— .................................À¡“¬‡≈¢‚∑√»æ— ∑å.....................

Û. ¢“â 懮â“................π..“..¬....°.......................... ‡≈¢ª√–®”μ—«ª√–™“™π ºâŸ...∂..Õ◊...°..√..√..¡.. ...‘∑..∏..‘Ï...............

................................................
Õ“¬.ÿ .................................ªï  ≠— ™“μ.‘ ........................................∫‘¥“/¡“√¥“™◊ËÕ.............................................................................

‚ ¥ À¡“â ¬ §à Ÿ ¡√ ™Ë◊Õ....................................................... ≠— ™“μ‘.......................
Õ¬Ÿ∑à Ë∫’ â“π/À¡à∫Ÿ â“π..........................‡≈¢∑’.Ë ...............μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡∑Ÿà .Ë’ .............
μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«¥— .................................À¡“¬‡≈¢‚∑√»æ— ∑.å ....................

Ù. ¢“â 懮“â ¢Õ· ¥ß√“§“∑√—æ¬∑å Ë’¢Õ∑”π‘μ°‘ √√¡πÈ’‡ªìπ‡ß‘π.............................›............................∫“∑.........›........... μ“ߧå
ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à

(Ò) ¢“â 懮“â ‰¡à‰¥√â —∫‚Õπ·∑πÀ√◊Õ‡æËÕ◊ ª√–‚¬™π·å °∫à §ÿ §≈μ“à ߥ⓫
(Ú) √“§“∑√—æ¬∑å ’Ë· ¥ß‰«â„π Ù. ‡ªπì √“§“∑·’Ë ∑®â √‘ß
(Û) .·..∫..ßà..·...¬..°..„.π...π..“..¡..‡..¥..‘¡....(.§..√..Õ...∫..›..ª..≈...Õ..¥..¿...“..√..–..®..”..¬..Õ..¡..)...μ...“.¡...§..”..¢..Õ..≈...ß..«..—π..∑...Ë’........................‡.¥..◊Õ...π...............................................æ.....»....................................
(Ù) .....................................................................................................................................................................
(ı) .....................................................................................................................................................................

«π— ∑.Ë’ ...........‡¥Õ◊ π..............................æ.»..................
≈ß™◊ËÕ.....................π..“..¬...°...........................ºâŸ¢Õ ∂◊Õ°√√¡ ‘∑∏‘Ï
≈ß™◊ËÕ.....................π..“..¬...°..........................ºâŸ¢Õ ∂Õ◊ °√√¡ ∑‘ ∏‘Ï
≈ß™◊ËÕ......................................................º âŸ Õ∫ «π

(......................................................)
 ”À√∫— æπ—°ß“π‡®“â Àπ“â ∑’Ë

Ò) √“§“ª√–‡¡π‘ ∑ÿπ∑√æ— ¬å.....................................................................................................∫“∑........................................ μ“ߧå
Ú) ‚©π¥∑’Ë¥‘π„À¡√à –«“ß......5..1..3..6...I.V.....7.2..2..8..-.1...............‡≈¢∑¥’Ë π‘ .................Ò.....Ò.........................Àπâ“ ”√«®.........Û..Ù..ˆ............................

‚©π¥∑¥’Ë ‘π‡≈¢∑.’Ë ....................ˆ..Ú..Û...Ù.......................‡≈à¡........................ˆ..Û............................Àπâ“..................Û..Ù..............................
®”π«π∑¥Ë’ π‘ ............................Ò..........................‰√.à .............................›...................ß“π..............................›....................μ“√“ß«“
§ß‡À≈Õ◊ .................................Ò..........................‰√.à .............................›...................ß“π..............................›....................μ“√“ß«“
Û) ‰¥®â ¥∑–‡∫¬’ π·≈«â ·μ«à π— ∑’Ë.................................‡¥◊Õπ............................................æ.»......................

≈ß™ËÕ◊ .......................................................
(......................................................)
‡®â“æπ—°ß“π∑Ë’¥‘π

μ—«Õ¬à“ßÀ¡“¬‡≈¢ Ò ÒÛÒ

(∑.¥. Òˆ)

∫π— ∑°÷ ¢âÕμ°≈ߪ≈Õ¥¿“√–®”¬Õ¡

∑’Ë¥‘π
√–«“ß..................5..1..3..6...I..V....7..2..2.8..-..1.....................................μ”∫≈........................................................................
‡≈¢∑’¥Ë ‘π...............Ò................Àπâ“ ”√«®........Û...Ù..Ù...............Õ”‡¿Õ.......................................................................
‚©π¥À¡“¬‡≈¢∑’Ë..............Ò..Û..ı.............................................®—ßÀ«—¥.......................................................................

∑«’Ë “à °“√.....................................................................

«π— ∑.Ë’ ...............‡¥◊Õπ........................................æ.».....................

¢“â 懮“â .....................π..“..¬....°.......‡.®..“â..¢..Õ..ß..¿...“..√..¬..∑..√..æ—...¬..å .................................. ‡≈¢ª√–®”μ—«ª√–™“™π

.....................π..“..¬....¢.......‡.®..“â ..¢..Õ..ß.. ...“..¡..¬..∑..√..æ—...¬..å ..................................

Õ“¬.ÿ ..................ªï ‡™È◊Õ™“μ.‘ .............................. ≠— ™“μ‘...............................∫‘¥“/¡“√¥“™◊ËÕ............................................................

Õ¬∑àŸ Ë∫’ “â π/À¡à∫Ÿ “â π......................................‡≈¢∑Ë.’ .............μ√Õ°/´Õ¬.....................................∂ππ.................................À¡Ÿà∑’.Ë .........

μ”∫≈/·¢«ß...............................Õ”‡¿Õ/‡¢μ...............................®ß— À«—¥................................À¡“¬‡≈¢‚∑√»æ— ∑.å .............................

¢//Õ//ª//Ø//‘≠//“/≥///μ//π//·/≈//–//„/À//â∂//Õâ //¬/§//”//μ/àÕ//......‰.¥..â∑...”..∫..—π..∑...÷°..¢..Õâ..μ...°..≈..ß..μ...Õà ..‡.®..“â..æ...π..—°..ß..“..π..∑...’¥Ë ..π‘.....................................................................................

¥//â«//¬//§//«/“/¡// //—μ//¬//å®/√//ß‘ / ¥—ßμÕà ‰ªπÈ’ :›
......................¢..âÕ....Ò.......μ...“..¡..∑...’Ë¢..â“..æ...‡.®..“â....π..“..¬....°......‡.®..â“..¢...Õ..ß..¿...“..√..¬..∑...√..—æ..¬...å .‰..¥..®â..¥...∑..–...‡.∫...’¬..π..¿...“..√..–..®..”..¬...Õ..¡...∑..’Ë¥...‘π..·...ª..≈...ß..π..’ȉ..«..â·..°...à .π...“..¬....¢.....‡..®..“â ..¢..Õ..ß...........
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............................................................................................≈..ß...™..◊ËÕ.....................................................................................................................................‡.®..“â..æ...π...°— ..ß..“..π..∑...¥Ë’..π‘..........................
..........................................................................................................ª..√..–..∑...—∫..μ...√..“..μ...”.·...À..π...ßà ..‡.ª...πì.. ...”..§..≠—..........................................................

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μ«— Õ¬“à ßÀ¡“¬‡≈¢ Ò ÒÛÚ

 “√∫—≠®¥∑–‡∫’¬π (√“¬°“√®¥∑–‡∫¬’ π·ª≈߇¥‘¡‚©π¥∑’ˇªπì ¿“√¬∑√æ— ¬å)

®¥∑–‡∫’¬π ª√–‡¿∑°“√ ºŸâ„À â ≠— ≠“ ºâŸ√—∫ —≠≠“ ‡πÈ◊Õ∑Ë’¥‘π ‡π◊ÈÕ∑’Ë¥‘π √–«“ß ‡®â“æπ—°ß“π∑Ë’¥‘π
«π— ‡¥◊Õπ ªï ®¥∑–‡∫’¬π μ“¡ —≠≠“ §ß‡À≈Õ◊ ‡≈¢∑Ë’¥‘π ≈ß≈“¬¡Õ◊ ™Õ◊Ë
‚©π¥∑Ë¥’ π‘ „À¡à ª√–∑∫— μ√“
‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
«“ «“

«—π∑Ë’.................. ¿“√–®”¬Õ¡ ∑’Ë¥π‘ ·ª≈ßπμÈ’ °Õ¬Ÿà„π∫—ߧ—∫¿“√–®”¬Õ¡‡√Ë◊Õß∑“߇¥π‘ ∑“ß√∂¬πμå ‰øø“Ñ ª√–ª“ (≈ß™◊ËÕ) 𓬠 .
‡¥Õ◊ π................ μ≈Õ¥®π “∏“√≥ªŸ ‚¿§μ“à ßÊ ¢Õß∑Ë¥’ π‘ ‚©π¥‡≈¢∑’Ë ÒÛıÛ Õ”‡¿Õ............................
æ.». .................. ®ß— À«—¥.......................μ“¡∫π— ∑÷°¢Õâ μ°≈ß©∫∫— ≈ß«—π∑.Ë’ ......‡¥Õ◊ π......................æ.».......... 5136IV 7228›1 (≈ß™Õ◊Ë ).........................
«—π∑’.Ë ................. ·∫ßà ·¬°„ππ“¡‡¥¡‘ Ò
‡¥Õ◊ π................ (§√Õ∫›ª≈Õ¥ 𓬠°. 𓬠°. Ò››Ú›› ˆÚÛÛ
æ.»................... ¿“√–®”¬Õ¡)
∑¥’Ë π‘ ·ª≈ß∑·’Ë ¬°‰ªπ’ȉ¡¡à ¿’ “√–®”¬Õ¡μ“¡

∫π— ∑°÷ ¢Õâ μ°≈ߪ≈Õ¥¿“√–®”¬Õ¡ ©∫∫—

≈ß«π— ∑.Ë’ ........‡¥Õ◊ π..................æ.»...........

Ò››Ò›› 5136IV 7228›1 (≈ß™Õ◊Ë ).........................
∑¥’Ë π‘ ·ª≈ß∑·’Ë ¬°‰ªπ·’È ≈–·ª≈ߧ߇À≈Õ◊ ÒÒ
¿“√–®”¬Õ¡¬ß— §ß¡Õ’ ¬μŸà “¡∫π— ∑°÷ ¢Õâ μ°≈ß ˆÚÛÙ
®¥∑–‡∫¬’ π¿“√–®”¬Õ¡ ©∫∫— ≈ß«π— ∑.’Ë ........
‡¥Õ◊ π..................æ.»...........

À¡“¬‡Àμÿ  “√∫—≠®¥∑–‡∫’¬π·ª≈ß·¬° ‚©π¥‡≈¢∑Ë’ ˆÚÛÛ ª≈Õ¥¿“√–®”¬Õ¡‰¡àμÕâ ߬°√“¬°“√®¥·®ßâ ·μÕà ¬à“ß„¥

μ«— Õ¬“à ßÀ¡“¬‡≈¢ Ò

 “√∫≠— ®¥∑–‡∫¬’ π

(√“¬°“√®¥·®âß∑’Ë¥‘π·ª≈ß∑’Ë·¬°‰ª„À¡à ‚©π¥‡≈¢∑’Ë ˆÚÛÙ Õ”‡¿Õ........)

®¥∑–‡∫¬’ π ª√–‡¿∑°“√ ºâŸ„À â ≠— ≠“ ºŸâ√—∫ —≠≠“ ‡π◊ÈÕ∑Ë’¥‘π ‡πÈ◊Õ∑’Ë¥‘π √–«“ß ‡®â“æπ—°ß“π∑Ë’¥‘π
«π— ‡¥Õ◊ π ªï ®¥∑–‡∫’¬π μ“¡ ≠— ≠“ §ß‡À≈Õ◊ ‡≈¢∑Ë’¥‘π ≈ß≈“¬¡Õ◊ ™ÕË◊
‚©π¥∑’¥Ë π‘ „À¡à ª√–∑∫— μ√“
‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
«“ «“

«—π∑.’Ë ................. ¿“√–®”¬Õ¡ ∑Ë¥’ ‘π·ª≈ßπÈ’μ°Õ¬àŸ„π∫ß— §∫— ¿“√–®”¬Õ¡‡√ËÕ◊ ß∑“߇¥‘π ∑“ß√∂¬πμå ‰øø“Ñ ª√–ª“ (≈ß™◊ËÕ) 𓬠 .
«—π∑Ë.’ ............................
‡¥Õ◊ π................ (§√Õ∫¿“√–®”¬Õ¡) μ≈Õ¥®π “∏“√≥ªŸ ‚¿§μ“à ßÊ ¢Õß∑¥Ë’ ‘π‚©π¥‡≈¢∑Ë’ ÒÛıÛ Õ”‡¿Õ................................ ‡¥Õ◊ π..........................
æ.». .............................
æ.». .................. ®—ßÀ«—¥........................μ“¡∫π— ∑°÷ ¢Õâ μ°≈ß©∫∫— ≈ß«π— ∑’.Ë ........‡¥Õ◊ π...................æ.»............. (≈ß™◊ÕË ).......................

ÒÛÛ

ÒÛÙ

μ«— Õ¬“à ßÀ¡“¬‡≈¢ ÒÒ (∑.¥. Ò)
∑∫Ë’ “â π

∑ Ë’ «π/‰√à

∑Ë’π“

∑’Ë..............

§”¢Õ®¥∑–‡∫’¬π ∑‘ ∏‘·≈–π‘μ‘°√√¡ πÕ°‡¢μ
·≈–°“√ Õ∫ «π ‘∑∏‘„π∑’¥Ë ‘π ª√–‡¿∑...‡..≈..‘°..¿...“..√..–..®..”.¬...Õ..¡.................... „π‡¢μ

μ”·Àπàß∑’Ë¥‘π

√–«“ß......................................................................................... μ”∫≈.........................................................................................

‡≈¢∑Ë’¥π‘ ..................................................................................... Õ”‡¿Õ........................................................................................

Àπâ“ ”√«®..................................................................................®ß— À«—¥........................................................................................

¿“√–®”¬Õ¡´Ë÷ß®¥∑–‡∫’¬π‰«âμ“¡∫—π∑÷°¢âÕμ°≈ß©∫—∫≈ß«—π∑’Ë.........‡¥◊Õπ....................æ.».............‡ªìπ —Õπ È‘ π‰ª‚©π¥∑Ë¥’ ‘π ÒÛı
‚¥¬§Ÿà°√≥’μ°≈߇≈‘°®“°°—π·≈â« μ“¡∫—π∑÷° â¢Õμ°≈ß©∫—∫≈ß«—π∑Ë’.........‡¥◊Õπ....................æ.»............. ‡≈¢∑Ë.’ ....................Ò..Û..ı...Û................‡≈à¡........................................Àπâ“....................................

‡ ⮓æπ—°ß“π Ë’∑¥‘π ®”π«π∑¥’Ë π‘ ...................................‰√.à ................................ß“π...................................μ“√“ß«“

Ò. ¢“â 懮⓺Ÿâ¡’π“¡μÕà ‰ªπÈ’ ¡§’ «“¡ª√– ß§¢å Õ®¥∑–‡∫’¬π ∑‘ ∏‘·≈–π‘μ‘°√√¡‡°Ë’¬«°∫— Õ —ßÀ“√¡‘ ∑√—æ¬å∑°’Ë ≈à“«¢â“ß∫ππ’È ·≈–

‰¥ªâ Ø≠‘ “≥μπ·≈«â ¢Õ„Àâ∂Õâ ¬§”¥«â ¬§«“¡ —쬮å √ß‘ ∂“â ¢“â 懮ⓄÀâ∂Õâ ¬§”‰¡à‡ªì𧫓¡®√ß‘ „Àâ„™â∂Õâ ¬§”πÈ’¬—π¢â“懮“â „π∑“ߧ¥’Õ“≠“‰¥â

Ú. ¢“â 懮“â ....π..“..¬...°.......‡..®..â“.¢...Õ..ß..¿..“..√..¬..∑...√..æ— ..¬...å .. ‡≈¢ª√–®”μ—«ª√–™“™π ºŸâ...¢..Õ.................................

.................................................

Õ“¬ÿ..................................ªï  —≠™“μ‘.........................................∫‘¥“/¡“√¥“™ËÕ◊ .............................................................................

‚ ¥ À¡“â ¬ §à Ÿ ¡√ ™ËÕ◊ ..........................................................................................

Õ¬Ÿ∑à ∫’Ë â“π/À¡Ÿ∫à â“π..........................‡≈¢∑.’Ë ...............μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡àŸ∑’Ë..............

μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«¥— .................................À¡“¬‡≈¢‚∑√»—æ∑å.....................

Û. ¢â“懮“â ...π..“..¬....¢.......‡.®..â“..¢..Õ..ß... ..“..¡..¬..∑...√..æ— ..¬..å... ‡≈¢ª√–®”μ—«ª√–™“™π ºâ.Ÿ ..¢..Õ.................................

................................................
Õ“¬ÿ..................................ªï  ≠— ™“μ‘.........................................∫¥‘ “/¡“√¥“™Õ◊Ë .............................................................................

‚ ¥ À¡“â ¬ §àŸ ¡√ ™◊ÕË ....................................................... —≠™“μ.‘ ......................
Õ¬Ÿà∑’∫Ë “â π/À¡à∫Ÿ “â π..........................‡≈¢∑’Ë................μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡à∑Ÿ ’Ë..............
μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®—ßÀ«¥— .................................À¡“¬‡≈¢‚∑√»—æ∑.å ....................

Ù. ¢â“懮ⓢշ ¥ß√“§“∑√—æ¬å∑Ë¢’ Õ∑”π‘μ‘°√√¡π’ȇªπì ‡ß‘π.............................›............................∫“∑.........›........... μ“ߧå
ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à

(Ò) ¢“â 懮Ⓣ¡à‰¥â√∫— ‚Õπ·∑πÀ√◊Õ‡æ◊ËÕª√–‚¬™π·å °∫à §ÿ §≈μà“ߥ⓫
(Ú) √“§“∑√—æ¬å∑’Ë· ¥ß‰«â„π Ù. ‡ªìπ√“§“∑·’Ë ∑â®√‘ß
(Û) .....................................................................................................................................................................
(Ù) .....................................................................................................................................................................
(ı) .....................................................................................................................................................................

«π— ∑.’Ë ...........‡¥Õ◊ π..............................æ.»..................
≈ß™◊ËÕ.....................π..“..¬...°...........................ºŸâ¢Õ ‡®“â ¢Õß¿“√¬∑√æ— ¬å
≈ß™Ë◊Õ.....................π..“..¬...¢..........................ºŸâ¢Õ ‡®“â ¢Õß “¡¬∑√æ— ¬å
≈ß™ËÕ◊ ......................................................º âŸ Õ∫ «π

(......................................................)
 ”À√—∫æπ°— ß“π‡®â“Àπâ“∑’Ë
Ò) √“§“ª√–‡¡π‘ ∑ÿπ∑√æ— ¬å.....................................................................................................∫“∑........................................ μ“ߧå
Ú) ‚©π¥∑¥Ë’ ‘π„À¡√à –«“ß............................................‡≈¢∑Ë¥’ ‘π...............................................Àπâ“ ”√«®.........................................
‚©π¥∑Ë¥’ ‘π‡≈¢∑’Ë...................................................‡≈à¡......................................................Àπ“â ..................................................
®”π«π∑¥’Ë π‘ ......................................................‰√.à ................................................ß“π..................................................μ“√“ß«“
§ß‡À≈Õ◊ ...........................................................‰√.à ................................................ß“π..................................................μ“√“ß«“
Û) ‰¥®â ¥∑–‡∫¬’ π·≈«â ·μ«à π— ∑’Ë.................................‡¥Õ◊ π............................................æ.»......................

≈ß™◊ËÕ.......................................................
(......................................................)
‡®â“æπ—°ß“π∑’Ë¥‘π

μ«— Õ¬à“ßÀ¡“¬‡≈¢ ÒÒ ÒÛı

(∑.¥. Òˆ)

∫—π∑°÷ ¢Õâ μ°≈߇√◊ÕË ß‡≈‘°¿“√–®”¬Õ¡

∑’Ë¥‘π

√–«“ß...............................................................................μ”∫≈........................................................................
‡≈¢∑¥Ë’ ‘π...............................Àπâ“ ”√«®............................Õ”‡¿Õ.......................................................................
‚©π¥À¡“¬‡≈¢∑’.Ë ......................Ò..Û..ı....................................®—ßÀ«—¥.......................................................................

ÒÛıÛ
∑Ë’«à“°“√.....................................................................

«π— ∑.’Ë ...............‡¥◊Õπ........................................æ.».....................

¢“â 懮“â .....................π..“..¬....°.......‡.®..â“..¢..Õ..ß..¿...“..√..¬..∑..√..—æ...¬..å .................................. ‡≈¢ª√–®”μ—«ª√–™“™π

.....................π..“..¬....¢.......‡.®..“â ..¢..Õ..ß.. ...“..¡..¬..∑..√..—æ...¬..å ..................................

Õ“¬.ÿ ..................ªï ‡™Õ◊È ™“μ‘............................... —≠™“μ‘...............................∫‘¥“/¡“√¥“™ËÕ◊ ............................................................

Õ¬àŸ∑Ë’∫“â π/À¡à∫Ÿ â“π......................................‡≈¢∑Ë.’ .............μ√Õ°/´Õ¬.....................................∂ππ.................................À¡Ÿ∑à .Ë’ .........

μ”∫≈/·¢«ß...............................Õ”‡¿Õ/‡¢μ...............................®—ßÀ«—¥................................À¡“¬‡≈¢‚∑√»æ— ∑å..............................
¢//Õ//ª//Ø//‘≠//“/≥///μ//π//·/≈//–//„/À//â∂//âÕ//¬/§//”//μ/àÕ//......‰.¥..∑â...”..∫..—π..∑...÷°..¢..Õâ..μ...°..≈..ß..μ...Õà ..‡.®..“â..æ...π..—°..ß..“..π..∑...Ë¥’ ..‘π.....................................................................................

¥//â«//¬//§//«/“/¡// //μ—//¬//®å /√//‘ß/ ¥—ßμÕà ‰ªπÈ’ :›
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.‚.©..π...¥..∑...’Ë .Ò...Û..ı.......Õ..”..‡..¿..Õ.............................................®...—ß..À..«..¥—............................................μ..°...Õ..¬...àŸ„.π...∫..—ß..§...∫—..¿...“..√..–..®..”..¬...Õ..¡...‡.√..Õ◊Ë...ß..∑..“..ß..‡..¥..‘π....∑...“..ß..√..∂..¬...π..μ...å .‰..ø..ø...“Ñ...ª...√..–..ª...“...μ...≈..Õ...¥..®...π...
. ..“..∏..“..√..≥....ªŸ ..‚..¿..§...μ..à“..ß..Ê....¢..Õ...ß..∑...’Ë¥..π‘...‚.©..π...¥..∑...’Ë .Ò...Û..ı...Û....Õ..”..‡.¿...Õ.................................................®..ß—..À...«..¥— .................................................π..—πÈ....∫...—¥..π...È’ .¢...â“..æ..‡..®..“â ...π...“..¬....°.....‡..®..“â ..¢..Õ..ß...¿..“..√..¬...∑..√..—æ...¬..å
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......................∫...—π..∑...°÷ ..¢..Õâ...μ..°...≈..ß..π...∑’È ..”..‰..«..â .Ò....©...∫..∫—....‡..°..∫Á...‰.«..â..≥..... ..”..π..—°...ß..“..π..∑...¥Ë’ ..π‘....∑...ß—È .. ..Õ...ß..Ω..“É..¬...‰.¥...âμ..√..«..®...¥..∫Ÿ...—π..∑...°÷ ..¢..Õâ...μ..°...≈..ß..·...≈..–..‡..¢..“â..„.®...¢..Õâ ..§...«..“..¡..μ...≈..Õ...¥.
·...≈..â«....®..÷ß..‰..¥..≈â...ß..≈..“..¬...¡..◊Õ...™..ÕË◊ ..À...√..Õ◊..æ...‘¡...æ..≈å...“..¬..π..«È‘..¡...◊Õ..‰..«..‡â.ª...πì ..À...≈..—°...∞..“..π..μ...àÕ..À...π..â“..æ...¬..“..π...·..≈..–...‡.®..“â..æ...π..°—...ß..“..π..∑...¥Ë’ ..‘π...............................................................

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............................................................................................≈..ß...™..◊ËÕ..................................π...“...¬.....°...............................‡.®..“â..¢...Õ..ß..¿...“..√..¬..∑...√..æ— ...¬..å ...................
............................................................................................≈..ß...™..◊ËÕ...........................................................π......“....¬.........¢.......................................................‡.®..“â..¢...Õ..ß.. ...“..¡..¬...∑..√..æ—...¬..å...................
............................................................................................≈..ß...™..Ë◊Õ....................................................................................................................................æ...¬..“..π...........................................
............................................................................................≈..ß...™..Ë◊Õ.....................................................................................................................................æ...¬..“..π...........................................
.............................∫...—π..∑...°÷ ..¢..âÕ...μ..°...≈..ß..π...’ȉ..¥..∑â...”..μ..Õà...À..π...“â ......................................................................................................................................
............................................................................................≈..ß...™..◊ËÕ.....................................................................................................................................‡.®..“â..æ...π...°— ..ß..“..π..∑...¥Ë’..π‘..........................
..........................................................................................................ª..√..–..∑...—∫..μ...√..“..μ...”.·...À..π...ßà ..‡.ª...ìπ.. ...”..§..—≠..........................................................

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μ«— Õ¬“à ßÀ¡“¬‡≈¢ ÒÒ ÒÛˆ

 “√∫—≠®¥∑–‡∫¬’ π

®¥∑–‡∫¬’ π ª√–‡¿∑°“√ ºâŸ„À â ≠— ≠“ ºŸâ√—∫ —≠≠“ ‡πÈ◊Õ∑’Ë¥‘π ‡πÈ◊Õ∑’Ë¥‘π √–«“ß ‡®â“æπ—°ß“π∑Ë’¥‘π
«π— ‡¥Õ◊ π ªï ®¥∑–‡∫¬’ π μ“¡ ≠— ≠“ §ß‡À≈Õ◊ ‡≈¢∑Ë’¥‘π ≈ß≈“¬¡Õ◊ ™Õ◊Ë
‚©π¥∑¥Ë’ π‘ „À¡à ª√–∑∫— μ√“
«—π∑’Ë.................. ‡≈°‘ ¿“√–®”¬Õ¡ ‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
‡¥◊Õπ................ «“ «“
æ.». ..................
¿“√–®”¬Õ¡´÷Ëß®¥∑–‡∫¬’ π‰«âμ“¡∫π— ∑÷°¢Õâ μ°≈ß©∫∫— ≈ß«—π∑.’Ë .........‡¥Õ◊ π................... (≈ß™◊ËÕ).......................
æ.»..................‡ªπì Õπ—  Èπ‘ ‰ª ‚¥¬§àŸ°√≥μ’ °≈߇≈‘°®“°°—π·≈«â μ“¡∫π— ∑÷°¢Õâ μ°≈ß
©∫∫— ≈ß«π— ∑’.Ë ........‡¥◊Õπ......................æ.».............

ÒÛ˜

μ—«Õ¬à“ßÀ¡“¬‡≈¢ ÒÚ (∑.¥. Ò)
∑∫’Ë “â π

∑’Ë «π/‰√à
(‚©π¥∑ˇ’ ªìπ·ª≈ß¿“√¬∑√—æ¬å) ∑Ë’π“

∑.’Ë .............

’Ë∑ ‘¥π·ª≈ßπÈ’μ°Õ¬àŸ„π∫—ß —§∫¿“√–®”¬Õ¡‡√Ë◊Õß∑“߇¥‘π ∑“ß√∂¬πμå ‰øøÑ“ ª√–ª“ μ≈Õ¥®π “∏“√≥Ÿª‚¿§μà“ßÊ ¢Õß∑Ë’¥‘π‚©π¥∑Ë’ ÒÛıÛ Õ”‡¿Õ.............®—ßÀ«—¥............. §”¢Õ®¥∑–‡∫¬’ π ‘∑∏·‘ ≈–π‘μ‘°√√¡ πÕ°‡¢μ
‚¥¬¡’‡ ◊ßËÕπ‰¢«à“ â∂“‡®â“¢Õß “¡¬∑√—æ¬å‚Õπ∑Ë’ ‘¥π„Àâ ÿ∫§§≈ÕË◊π¿“√–®”¬Õ¡‡ªìπÕ—π ‘È π‰ª μ“¡∫—π∑÷°¢âÕμ°≈ß©∫—∫≈ß«—π∑Ë’.........‡¥◊Õπ....................æ.»............. ·≈–°“√ Õ∫ «π ∑‘ ∏‘„π∑’Ë¥π‘ ª√–‡¿∑...¿...“..√..–..®..”..¬..Õ..¡....(.¡...’‡.ß..◊ÕË..π...‰.¢..)....... „π‡¢μ

‡®â“æπ—°ß“π ’Ë∑¥‘π μ”·Àπàß∑’Ë¥‘π

√–«“ß......................................................................................... μ”∫≈.........................................................................................

‡≈¢∑Ë’¥π‘ ..................................................................................... Õ”‡¿Õ........................................................................................

Àπâ“ ”√«®..................................................................................®—ßÀ«¥— ........................................................................................

‚©π¥∑¥’Ë π‘ ÒÛı
‡≈¢∑Ë’.....................Ò..Û..ı...Û................‡≈¡à ........................................Àπ“â ....................................

®”π«π∑’Ë¥π‘ ...................................‰√à.................................ß“π...................................μ“√“ß«“

Ò. ¢“â 懮“⠺⟡’π“¡μàÕ‰ªπÈ’ ¡’§«“¡ª√– ß§¢å Õ®¥∑–‡∫’¬π ‘∑∏·‘ ≈–π‘μ°‘ √√¡‡°¬Ë’ «°—∫Õ ß— À“√‘¡∑√—æ¬∑å Ë°’ ≈“à «¢â“ß∫ππÈ’ ·≈–

‰¥ªâ Ø‘≠“≥μπ·≈â« ¢Õ„Àâ∂âÕ¬§”¥â«¬§«“¡ μ— ¬®å √‘ß ∂“â ¢“â 懮“â „Àâ∂âÕ¬§”‰¡à‡ªì𧫓¡®√‘ß„Àâ„™∂â âÕ¬§”π’È¬π— ¢â“懮“â „π∑“ߧ¥’Õ“≠“‰¥â

Ú. ¢â“懮â“....π..“..¬...°.......‡..®..â“.¢...Õ..ß..¿..“..√..¬..∑...√..æ— ..¬...å .. ‡≈¢ª√–®”μ—«ª√–™“™π º.Ÿâ ..¢..Õ.................................

.................................................

Õ“¬ÿ..................................ªï  ≠— ™“μ‘.........................................∫¥‘ “/¡“√¥“™ÕË◊ .............................................................................

‚ ¥ À¡“â ¬ §Ÿà ¡√ ™◊ÕË ..........................................................................................

Õ¬Ÿ∑à Ë’∫“â π/À¡à∫Ÿ â“π..........................‡≈¢∑’.Ë ...............μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡Ÿ∑à Ë.’ .............

μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®—ßÀ«—¥.................................À¡“¬‡≈¢‚∑√»æ— ∑å.....................

Û. ¢â“懮“â ...π..“..¬....¢.......‡.®..â“..¢..Õ..ß... ..“..¡..¬..∑...√..—æ..¬..å... ‡≈¢ª√–®”μ—«ª√–™“™π ºâŸ...¢..Õ.................................

................................................
Õ“¬.ÿ .................................ªï  —≠™“μ‘.........................................∫¥‘ “/¡“√¥“™◊ÕË .............................................................................

‚ ¥ À¡“â ¬ §àŸ ¡√ ™Ë◊Õ....................................................... —≠™“μ‘.......................
Õ¬∑Ÿà ’Ë∫â“π/À¡Ÿ∫à “â π..........................‡≈¢∑.Ë’ ...............μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡∑àŸ Ë.’ .............
μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®—ßÀ«—¥.................................À¡“¬‡≈¢‚∑√»—æ∑.å ....................

Ù. ¢“â 懮ⓢշ ¥ß√“§“∑√—æ¬å∑Ë’¢Õ∑”π‘μ°‘ √√¡π‡È’ ªπì ‡ß‘π.............................›............................∫“∑.........›........... μ“ߧå
ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à

(Ò) ¢â“懮Ⓣ¡à‰¥â√—∫‚Õπ·∑πÀ√◊Õ‡æË◊Õª√–‚¬™πå·°∫à §ÿ §≈μ“à ߥ“â «
(Ú) √“§“∑√æ— ¬å∑·’Ë  ¥ß‰«â„π Ù. ‡ªìπ√“§“∑·’Ë ∑®â √‘ß
(Û) ‰.¡..à¡..’§..à“..μ..Õ..∫..·..∑..π...(.¡..’§..à“.μ..Õ..∫..·..∑..π..‡.ª..πì..‡.ß..‘π...............................∫..“..∑..)...........................................................................................
(Ù) .....................................................................................................................................................................
(ı) .....................................................................................................................................................................

«π— ∑.Ë’ ...........‡¥Õ◊ π..............................æ.»..................
≈ß™◊ÕË .....................π..“..¬...°...........................ºŸâ¢Õ ‡®â“¢Õß¿“√¬∑√æ— ¬å
≈ß™Ë◊Õ.....................π..“..¬...¢..........................ºŸâ¢Õ ‡®“â ¢Õß “¡¬∑√æ— ¬å
≈ß™Õ◊Ë ......................................................º âŸ Õ∫ «π

(......................................................)
 ”À√∫— æπ°— ß“π‡®â“Àπ“â ∑’Ë
Ò) √“§“ª√–‡¡π‘ ∑πÿ ∑√æ— ¬.å ....................................................................................................∫“∑........................................ μ“ߧå
Ú) ‚©π¥∑’¥Ë ‘π„À¡√à –«“ß............................................‡≈¢∑’¥Ë π‘ ...............................................Àπâ“ ”√«®.........................................
‚©π¥∑’Ë¥π‘ ‡≈¢∑.Ë’ ..................................................‡≈¡à ......................................................Àπâ“..................................................
®”π«π∑¥’Ë π‘ ......................................................‰√.à ................................................ß“π..................................................μ“√“ß«“
§ß‡À≈Õ◊ ...........................................................‰√.à ................................................ß“π..................................................μ“√“ß«“
Û) ‰¥â®¥∑–‡∫¬’ π·≈â«·μà«π— ∑.’Ë ................................‡¥Õ◊ π............................................æ.»......................

≈ß™◊ËÕ.......................................................
(......................................................)
‡®â“æπ—°ß“π∑Ë’¥‘π

ÒÛ¯

μ—«Õ¬à“ßÀ¡“¬‡≈¢ ÒÚ (∑.¥. Òˆ)
(‚©π¥∑Ë’‡ªπì ·ª≈ß¿“√¬∑√—æ¬å)

∫π— ∑÷°¢âÕμ°≈߇√ËÕ◊ ß¿“√–®”¬Õ¡ (¡’‡ß◊ËÕπ‰¢)

∑’Ë¥‘π

√–«“ß...............................................................................μ”∫≈........................................................................

‡≈¢∑¥Ë’ ‘π...............................Àπ“â  ”√«®............................Õ”‡¿Õ.......................................................................
‚©π¥À¡“¬‡≈¢∑.’Ë .....................Ò...Û..ı....................................®—ßÀ«¥— .......................................................................

ÒÛıÛ
∑Ë’«“à °“√.....................................................................

«—π∑’Ë................‡¥Õ◊ π........................................æ.».....................

¢“â 懮“â .....................π..“..¬....°.......‡.®..“â..¢..Õ..ß..¿...“..√..¬..∑..√..æ—...¬..å .................................. ‡≈¢ª√–®”μ—«ª√–™“™π

.....................π..“..¬....¢.......‡.®..â“..¢..Õ..ß.. ...“..¡..¬..∑..√..æ—...¬..å..................................

Õ“¬ÿ...................ªï ‡™È◊Õ™“μ.‘ .............................. ≠— ™“μ‘...............................∫‘¥“/¡“√¥“™◊ËÕ............................................................

Õ¬Ÿ∑à ∫Ë’ “â π/À¡Ÿà∫“â π......................................‡≈¢∑Ë.’ .............μ√Õ°/´Õ¬.....................................∂ππ.................................À¡àŸ∑Ë’..........

μ”∫≈/·¢«ß...............................Õ”‡¿Õ/‡¢μ...............................®—ßÀ«¥— ................................À¡“¬‡≈¢‚∑√»æ— ∑å..............................
¢//Õ//ª//Ø//≠‘ //“/≥///μ//π//·/≈//–//„/À//∂â //Õâ //¬/§//”//μ/àÕ//......‰.¥..∑â...”..∫..π—..∑...÷°..¢..Õâ..μ...°..≈..ß..μ...Õà ..‡.®..â“..æ...π..°—..ß..“..π..∑...’Ë¥..‘π.....................................................................................

¥//«â//¬//§//«/“/¡// //—μ//¬//®å /√//‘ß/ ¥ß— μàÕ‰ªπÈ’ :›
......................¢..âÕ....Ò.......∑...’¥Ë ..‘π...μ..“..¡...‡.§...√..◊ÕË ..ß..À...¡..“..¬...¥..ß—..°...≈..“à..«..¢...â“.ß...∫..π...π..È’..‡.ª...ìπ..¿...“..√..¬..∑...√..—æ..¬...å·..≈...–.. ..“..¡...¬..∑..√...æ— ..¬...å·..°..°à...—π....‚.¥...¬..¢..â“..æ...‡.®...â“...π..“..¬....°......¬..‘π...¬..Õ...¡......
.„.À..â∑...Ë’¥..π‘...‚.©...π..¥...∑..Ë’..Ò..Û...ı......Õ...”..‡.¿..Õ...................................................®..—ß...À..«..¥—...............................................μ...°..Õ...¬..Ÿà„..π..∫...ß— ..§..∫—...¿..“..√..–...®..”..¬..Õ...¡..‡.√...ËÕ◊ ..ß..∑...“..ß..‡.¥...π‘ ....∑..“..ß..√..∂...¬..π...μ..å..‰.ø...ø..“Ñ....ª..√...–..ª..“....
.μ..≈..Õ...¥..®...π.. ...“.∏...“..√..≥...ªŸ...‚.¿...§..μ...à“..ß..Ê....¢..Õ..ß...∑..¥’Ë...π‘ ..‚..©..π..¥...∑..Ë’..Ò..Û...ı..Û....Õ...”..‡.¿...Õ.............................................®..—ß..À...«..¥— ......................................‚..¥..¬..¡...’‡.ß..◊ÕË...π..‰..¢..«..“à....∂..“â..‡.®...â“.¢...Õ..ß.. ...“..¡..¬...∑..√..æ—...¬..å...
.‚.Õ..π...∑..Ë¥’...‘π..„..À..â∫...§ÿ ..§...≈..Õ...Ë◊π..¿...“..√..–..®..”..¬...Õ..¡...‡.ª..ìπ...Õ..π—... ..π‘È...‰.ª....·...≈..–..¢...â“..æ..‡..®..“â ...π...“..¬....¢.....¬...Õ..¡...√..∫— ..ª...√..–..‚.¬...™..π...®å ..“..°..¿...“..√..–..®..”..¬..Õ...¡..¥...ß—..°..≈...à“..«..·..≈...«â ...........................
......................¢..âÕ....Ú.......°...“..√..¢..Õ...®..¥..∑...–..‡.∫...’¬..π...¿..“..√..–...®..”..¬..Õ...¡..¥...ß— ..°..≈...“à ..«..‰.¡..à¡...§’...à“.μ...Õ..∫...·..∑...π....(.¡...§’ ..à“..μ...Õ..∫...·..∑...π..‡.ª...πì..‡..ß..‘π....................................∫...“..∑..)...........................
......................¢..Õâ....Û.......¢...Õ..‡.®...“â ..æ..π...—°..ß..“..π...∑..’¥Ë...‘π..‰..¥..â‚..ª..√..¥...®..¥...∑..–..‡..∫..’¬...π..¿...“.√...–..®..”..¬..Õ...¡..„..À..âμ...“..¡..§...«..“..¡..ª...√..–.. ..ß...§..¢å..Õ...ß..¢..“â..æ...‡.®...â“.¥...â«..¬....¢..â“..æ...‡.®..â“..¬...Õ..¡...‡. ...¬’ ......
.§..à“..∏..√..√..¡...‡.π...¬’ ..¡...„.À...âμ..“..¡...√..–..‡.∫...’¬..∫.....................................................................................................................................................................
......................∫...—π..∑...÷°..¢..Õâ...μ..°...≈..ß..π...È’∑..”..‰..«..â .Ò....©...∫..—∫....‡..°..∫Á...‰.«..â..≥..... ..”..π..°—...ß..“..π..∑...Ë’¥..‘π....∑...—Èß.. ..Õ...ß..Ω..É“..¬...‰.¥...μâ ..√..«..®...¥..Ÿ∫...π— ..∑...÷°..¢..âÕ...μ..°...≈..ß..·...≈..–..‡..¢..â“..„.®...¢..Õâ ..§...«..“..¡..μ...≈..Õ...¥.
.·..≈..â«....®..÷ß..‰..¥..≈â...ß..≈..“..¬...¡..◊Õ...™..◊ÕË ..À...√..◊Õ..æ...¡‘...æ..å≈...“..¬..π..«È‘..¡...◊Õ..‰..«..‡â.ª...ìπ..À...≈..—°...∞..“..π..μ...Õà ..À...π..â“..æ...¬..“..π...·..≈..–...‡.®..“â..æ...π..—°...ß..“..π..∑...Ë¥’ ..‘π...............................................................

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............................................................................................≈..ß...™..Ë◊Õ...........................................................π......“....¬.........°.......................................................‡.®..â“..¢...Õ..ß..¿...“..√..¬..∑...√..æ— ...¬..å ...................
............................................................................................≈..ß...™..◊ËÕ...........................................................π......“....¬.........¢......................................................‡.®..“â..¢...Õ..ß.. ...“..¡..¬...∑..√..æ—...¬..å...................
............................................................................................≈..ß...™..Ë◊Õ....................................................................................................................................æ...¬..“..π...........................................
............................................................................................≈..ß...™..◊ËÕ.....................................................................................................................................æ...¬..“..π...........................................
.............................∫...π—..∑...°÷ ..¢...âÕ..μ...°..≈..ß..π...’ȉ..¥..∑â...”..μ..Õà...À..π...“â ......................................................................................................................................
............................................................................................≈..ß...™..◊ËÕ.....................................................................................................................................‡.®..“â..æ...π...°— ..ß..“..π..∑...¥Ë’..π‘..........................
..........................................................................................................ª..√..–..∑...—∫..μ...√..“..μ...”.·...À..π...ßà ..‡.ª...πì.. ...”..§..≠—..........................................................

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μ—«Õ¬“à ßÀ¡“¬‡≈¢ ÒÚ

 “√∫—≠®¥∑–‡∫¬’ π

(‚©π¥∑’‡Ë ªπì ¿“√¬∑√—æ¬)å

®¥∑–‡∫’¬π ª√–‡¿∑°“√ ºŸâ„À â ≠— ≠“ ºâŸ√—∫ —≠≠“ ‡π◊ÈÕ∑Ë’¥‘π ‡π◊ÈÕ∑Ë’¥‘π √–«“ß ‡®â“æπ—°ß“π∑Ë’¥‘π
«π— ‡¥Õ◊ π ªï ®¥∑–‡∫’¬π μ“¡ ≠— ≠“ §ß‡À≈Õ◊ ‡≈¢∑’Ë¥‘π ≈ß≈“¬¡Õ◊ ™ÕË◊
‚©π¥∑¥’Ë π‘ „À¡à ª√–∑∫— μ√“
«—π∑.Ë’ ................. ¿“√–®”¬Õ¡ ‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
‡¥Õ◊ π................ (¡’‡ßËÕ◊ π‰¢) «“ «“
æ.». ..................
∑¥Ë’ ‘π·ª≈ßπμ’È °Õ¬Ÿà„π∫—ߧ∫— ¿“√–®”¬Õ¡∑“߇¥‘π ∑“ß√∂¬πμå ‰øøÑ“ ª√–ª“ (≈ß™◊ÕË ).......................
μ≈Õ¥®π “∏“√≥ªŸ ‚¿§μà“ßÊ ¢Õß∑’Ë¥π‘ ‚©π¥∑Ë’ ÒÛıÛ Õ”‡¿Õ.................................
®—ßÀ«¥— ......................‚¥¬¡‡’ ßÕ◊Ë π‰¢«“à ∂Ⓡ®â“¢Õß “¡¬∑√æ— ¬å‚Õπ∑¥’Ë π‘ „À∫â ÿ§§≈ÕπË◊
¿“√–®”¬Õ¡‡ªìπÕ—π È‘π‰ª μ“¡∫—π∑÷°¢âÕμ°≈ß©∫∫— ≈ß«π— ∑’Ë.........‡¥Õ◊ π.....................
æ.». ........

ÒÛ˘

ÒÙ

μ—«Õ¬à“ßÀ¡“¬‡≈¢ ÒÚ (∑.¥.Ò)
∑∫’Ë “â π

∑’ Ë «π/‰√à

∑Ë’π“

∑’Ë..............

§”¢Õ®¥∑–‡∫’¬π ‘∑∏‘·≈–πμ‘ ‘°√√¡ πÕ°‡¢μ
·≈–°“√ Õ∫ «π ‘∑∏‘„π∑Ë¥’ ‘π ª√–‡¿∑...‡..≈..°‘..¿...“.√..–...®..”.¬...Õ..¡....(.¡..’‡..ß..ÕË◊ ..π..‰..¢..). „π‡¢μ

μ”·Àπàß∑’Ë¥‘π

√–«“ß......................................................................................... μ”∫≈.........................................................................................

‡≈¢∑¥Ë’ π‘ ..................................................................................... Õ”‡¿Õ........................................................................................

Àπ“â  ”√«®..................................................................................®ß— À«—¥........................................................................................

¿“√–®”¬Õ¡´Ë÷ß®¥∑–‡∫’¬π‰«âμ“¡∫—π∑÷°¢âÕμ°≈ß©∫—∫≈ß«—π∑Ë’.........‡ ◊¥Õπ....................æ.».............‡ ìªπ —Õπ ‘È π‰ª‚©π¥∑Ë’¥π‘ ÒÛı
‡æ√“–‡Àμÿ∑’ˇ ⮓¢Õß “¡¬∑√—æ¬å‰¥â‚Õπ∑Ë’ ‘¥π·ª≈ß “¡¬∑√—æ¬å„Àâ ÿ∫§§≈Õ◊Ëπ ‡≈¢∑.’Ë ....................Ò..Û..ı...Û................‡≈à¡........................................Àπâ“....................................

‡®â“æπ—°ß“π Ë’∑ ‘¥π ®”π«π∑’¥Ë π‘ ...................................‰√à.................................ß“π...................................μ“√“ß«“

Ò. ¢“â 懮⓺¡âŸ π’ “¡μÕà ‰ªπ’È ¡’§«“¡ª√– ß§å¢Õ®¥∑–‡∫¬’ π ∑‘ ∏‘·≈–πμ‘ °‘ √√¡‡°Ë¬’ «°∫— Õ ß— À“√‘¡∑√æ— ¬å∑Ë’°≈à“«¢“â ß∫ππ’È ·≈–

‰¥ªâ Ø≠‘ “≥μπ·≈«â ¢Õ„À∂â Õâ ¬§”¥â«¬§«“¡ μ— ¬å®√‘ß ∂“â ¢â“懮“â „Àâ∂Õâ ¬§”‰¡à‡ªì𧫓¡®√‘ß„Àâ„™∂â Õâ ¬§”π’È¬π— ¢â“懮Ⓞπ∑“ߧ¥’Õ“≠“‰¥â

Ú. ¢“â 懮“â ....π..“..¬...°.......‡..®..â“.¢...Õ..ß..¿..“..√..¬..∑...√..æ— ..¬...å .. ‡≈¢ª√–®”μ—«ª√–™“™π ºâ.Ÿ ..¢..Õ.................................

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Õ“¬ÿ..................................ªï  —≠™“μ.‘ ........................................∫‘¥“/¡“√¥“™ÕË◊ .............................................................................

‚ ¥ À¡“â ¬ §àŸ ¡√ ™Õ◊Ë ..........................................................................................

Õ¬∑Ÿà Ë∫’ â“π/À¡à∫Ÿ â“π..........................‡≈¢∑’.Ë ...............μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡Ÿà∑’.Ë .............

μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«—¥.................................À¡“¬‡≈¢‚∑√»æ— ∑å.....................

Û. ¢“â 懮â“.........................›........................ ‡≈¢ª√–®”μ—«ª√–™“™π º.⟠..¢..Õ.................................

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Õ“¬.ÿ .................................ªï  ≠— ™“μ‘.........................................∫¥‘ “/¡“√¥“™ËÕ◊ .............................................................................

‚ ¥ À¡“â ¬ §àŸ ¡√ ™Õ◊Ë ....................................................... —≠™“μ‘.......................
Õ¬∑àŸ Ë∫’ â“π/À¡Ÿà∫“â π..........................‡≈¢∑’.Ë ...............μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡∑àŸ .Ë’ .............
μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®—ßÀ«¥— .................................À¡“¬‡≈¢‚∑√»—æ∑å.....................

Ù. ¢â“懮ⓢշ ¥ß√“§“∑√æ— ¬∑å ¢Ë’ Õ∑”πμ‘ °‘ √√¡π‡È’ ªπì ‡ß‘π.............................›............................∫“∑.........›........... μ“ߧå
ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à

(Ò) ¢â“懮“â ‰¡à‰¥√â ∫— ‚Õπ·∑πÀ√◊Õ‡æÕË◊ ª√–‚¬™π·å °à∫ÿ§§≈μ“à ߥ⓫
(Ú) √“§“∑√—æ¬å∑’Ë· ¥ß‰«â„π Ù. ‡ªπì √“§“∑’Ë·∑®â √‘ß
(Û) .π..“..¬....¢....‡.®..â“..¢..Õ...ß.. ..“..¡..¬..∑...√..—æ..¬..å.‰.¥..¢â...“.¬...∑..¥Ë’..π‘...·..ª..≈...ß.. ..“..¡..¬...∑..√..—æ..¬...å‚.©..π...¥..∑..Ë’¥...π‘ ..‡.≈...¢..∑..Ë’..Ò..Û..ı...Û...„..À..â∫..ÿ§...§..≈..Õ...πË◊ ...........................

.μ..“..¡.. ...—≠...≠...“..¢..“..¬..∑..¥’Ë...‘π....©..∫..∫—...≈..ß..«..—π..∑...’Ë ...........‡.¥...◊Õ..π........................æ...»..................................................................................
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«π— ∑.’Ë ...........‡¥Õ◊ π..............................æ.»..................
≈ß™Ë◊Õ.....................π..“..¬...°...........................ºŸâ¢Õ ‡®“â ¢Õß¿“√¬∑√æ— ¬å
≈ß™ËÕ◊ ..........................›............................ºŸâ¢Õ
≈ß™Õ◊Ë ......................................................º âŸ Õ∫ «π

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 ”À√∫— æπ°— ß“π‡®â“Àπâ“∑’Ë
Ò) √“§“ª√–‡¡‘π∑πÿ ∑√—æ¬å.....................................................................................................∫“∑........................................ μ“ߧå
Ú) ‚©π¥∑Ë’¥‘π„À¡à√–«“ß............................................‡≈¢∑’Ë¥π‘ ...............................................Àπâ“ ”√«®.........................................
‚©π¥∑¥Ë’ π‘ ‡≈¢∑Ë’...................................................‡≈¡à ......................................................Àπâ“..................................................
®”π«π∑¥Ë’ π‘ ......................................................‰√.à ................................................ß“π..................................................μ“√“ß«“
§ß‡À≈Õ◊ ...........................................................‰√.à ................................................ß“π..................................................μ“√“ß«“
Û) ‰¥®â ¥∑–‡∫¬’ π·≈«â ·μ«à π— ∑Ë.’ ................................‡¥Õ◊ π............................................æ.»......................

≈ß™ËÕ◊ .......................................................
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‡®â“æπ—°ß“π∑Ë’¥‘π

μ«— Õ¬“à ßÀ¡“¬‡≈¢ ÒÚ ÒÙÒ

(∑.¥. Òˆ)

∫π— ∑÷°∂Õâ ¬§”‡≈‘°¿“√–®”¬Õ¡ (¡’‡ß◊ËÕπ‰¢)

∑’Ë¥‘π

√–«“ß...............................................................................μ”∫≈........................................................................

‡≈¢∑’¥Ë ‘π...............................Àπ“â  ”√«®............................Õ”‡¿Õ.......................................................................
‚©π¥À¡“¬‡≈¢∑.’Ë ......................Ò..Û..ı....................................®ß— À«—¥.......................................................................

ÒÛıÛ
∑Ë«’ à“°“√.....................................................................

«π— ∑Ë’................‡¥◊Õπ........................................æ.».....................

¢“â 懮“â .....................π..“..¬....°.......‡.®..â“..¢..Õ..ß..¿...“..√..¬..∑..√..æ—...¬..å .................................. ‡≈¢ª√–®”μ—«ª√–™“™π

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Õ“¬.ÿ ..................ªï ‡™ÕÈ◊ ™“μ‘............................... —≠™“μ.‘ ..............................∫¥‘ “/¡“√¥“™ËÕ◊ ............................................................

Õ¬àŸ∑Ë∫’ â“π/À¡à∫Ÿ â“π......................................‡≈¢∑Ë.’ .............μ√Õ°/´Õ¬.....................................∂ππ.................................À¡∑àŸ .Ë’ .........

μ”∫≈/·¢«ß...............................Õ”‡¿Õ/‡¢μ...............................®ß— À«¥— ................................À¡“¬‡≈¢‚∑√»—æ∑.å .............................
¢ÕªØ‘≠“≥μπ·≈–„Àâ∂âÕ¬§”μàÕ......‡.®..“â..æ..π...°— ..ß..“..π..∑..¥Ë’...π‘ ........................................................................................................................

¥â«¬§«“¡ —쬮å √ß‘ ¥ß— μÕà ‰ªπ’È :›
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.æ..¬...“.π...·..≈...–..‡.®...“â .æ...π...—°..ß..“..π...∑..Ë¥’...‘π.......................................................................................................................................................................

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............................................................................................≈..ß...™..Ë◊Õ...........................................................π......“....¬.........°.......................................................º..Ÿâ.„.À...â∂..âÕ..¬...§..”..................................
............................................................................................≈..ß...™..◊ËÕ....................................................................................................................................æ...¬..“..π...........................................
............................................................................................≈..ß...™..Ë◊Õ....................................................................................................................................æ...¬..“..π...........................................
............................................................................................≈..ß...™..Ë◊Õ.....................................................................................................................................‡.®..“â..æ...π...°— ..ß..“..π..∑...¥’Ë..π‘..........................

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μ«— Õ¬à“ßÀ¡“¬‡≈¢ ÒÚ ÒÙÚ

 “√∫≠— ®¥∑–‡∫¬’ π

®¥∑–‡∫’¬π ª√–‡¿∑°“√ ºŸâ„À â ≠— ≠“ ºŸâ√—∫ —≠≠“ ‡π◊ÈÕ∑Ë’¥‘π ‡πÈ◊Õ∑’Ë¥‘π √–«“ß ‡®â“æπ—°ß“π∑Ë’¥‘π
«—𠇥◊Õπ ªï ®¥∑–‡∫¬’ π μ“¡ —≠≠“ §ß‡À≈Õ◊ ‡≈¢∑Ë’¥‘π ≈ß≈“¬¡Õ◊ ™Õ◊Ë
‚©π¥∑’Ë¥‘π„À¡à ª√–∑∫— μ√“
«π— ∑.Ë’ ................. ¿“√–®”¬Õ¡ ‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
‡¥Õ◊ π................ (¡’‡ßËÕ◊ π‰¢) «“ «“
æ.». ..................
∑’Ë¥π‘ ·ª≈ßπμ’È °Õ¬Ÿà„π∫—ߧ—∫¿“√–®”¬Õ¡∑“߇¥π‘ ∑“ß√∂¬πμå ‰øø“Ñ ª√–ª“ (≈ß™◊ËÕ).......................
μ≈Õ¥®π “∏“√≥ªŸ ‚¿§μ“à ßÊ ¢Õß∑Ë’¥π‘ ‚©π¥∑Ë’ ÒÛıÛ Õ”‡¿Õ.....................................
®—ßÀ«—¥..........................‚¥¬¡‡’ ßÕË◊ π‰¢«à“ ∂“â ‡®â“¢Õß “¡¬∑√æ— ¬å‚Õπ∑’¥Ë ‘π„À∫â ÿ§§≈Õ◊πË
¿“√–®”¬Õ¡‡ªπì Õπ—  Èπ‘ ‰ª μ“¡∫π— ∑°÷ ¢Õâ μ°≈ß©∫—∫≈ß«—π∑Ë.’ ......‡¥Õ◊ π............æ.»........

«—π∑Ë.’ ................. ‡≈°‘ ¿“√–®”¬Õ¡ ¿“√–®”¬Õ¡´÷ßË ®¥∑–‡∫’¬π‰«μâ “¡∫—π∑°÷ ¢Õâ μ°≈ß©∫∫— ≈ß«—π∑Ë’.........‡¥◊Õπ.................... (≈ß™◊ÕË ).......................
‡¥◊Õπ................ (¡’‡ß◊ËÕπ‰¢) æ.».......................‡ªìπÕπ—  ‘πÈ ‰ª ‡æ√“–‡Àμ∑ÿ ’‡Ë ®“â ¢Õß “¡¬∑√—æ¬å‰¥â‚Õπ∑’¥Ë π‘ ·ª≈ß
æ.». ..................  “¡¬∑√—æ¬å„Àâ∫§ÿ §≈ÕπË◊ ·≈«â

ÒÙÛ

μ«— Õ¬“à ßÀ¡“¬‡≈¢ ÒÛ (∑.¥. Ò)
∑∫’Ë “â π

∑Ë ’ «π/‰√à

∑Ë’π“

∑’.Ë .............

πÕ°‡¢μ

§”¢Õ®¥∑–‡∫’¬π ∑‘ ∏·‘ ≈–π‘μ‘°√√¡ „π‡¢μ

·≈–°“√ Õ∫ «π ∑‘ ∏‘„π∑’¥Ë ‘π ª√–‡¿∑..‡.≈..‘°..√..“..¬..°...“..√..®..¥..∑..–..‡..∫..’¬..π...¿..“..√..–..®.”¬Õ¡

μ”·Àπàß∑’Ë¥‘π

√–«“ß......................................................................................... μ”∫≈.........................................................................................

‡≈¢∑’¥Ë ‘π..................................................................................... Õ”‡¿Õ........................................................................................

√“¬°“√®¥∑–‡∫’¬π¿“√–®”¬Õ¡ ÷Ë´ß®¥∑–‡ ’∫¬π‰ â«μ“¡ —∫π ÷∑° â¢Õμ°≈ß© —∫∫≈ß«—π ’Ë∑.........‡ ◊¥Õπ....................æ.»............. È—ππÀπâ“ ”√«®..................................................................................®—ßÀ«¥— ........................................................................................
‡ ìªπÕ—π¬°‡≈‘° μ“¡∫—π∑÷°∂âÕ¬§”©∫—∫≈ß«—π∑’Ë.........‡ ◊¥Õπ....................æ.».............
‚©π¥∑’¥Ë π‘
‡®â“æπ—°ß“π ’Ë∑ ‘¥π ‡≈¢∑Ë’.....................Ò..Û..ı...Û................‡≈¡à ........................................Àπ“â ....................................

®”π«π∑’¥Ë π‘ ...................................‰√.à ................................ß“π...................................μ“√“ß«“

Ò. ¢“â 懮“â ºâŸ¡π’ “¡μÕà ‰ªπÈ’ ¡§’ «“¡ª√– ß§å¢Õ®¥∑–‡∫¬’ π ‘∑∏‘·≈–πμ‘ °‘ √√¡‡°Ë’¬«°∫— Õ ß— À“√‘¡∑√æ— ¬∑å ’°Ë ≈à“«¢“â ß∫ππÈ’ ·≈–

‰¥âªØ≠‘ “≥μπ·≈«â ¢Õ„Àâ∂âÕ¬§”¥«â ¬§«“¡ μ— ¬®å √‘ß ∂“â ¢“â 懮ⓄÀâ∂âÕ¬§”‰¡à‡ªì𧫓¡®√ß‘ „Àâ„™∂â âÕ¬§”πȬ’ π— ¢â“懮Ⓞπ∑“ߧ¥Õ’ “≠“‰¥â

Ú. ¢“â 懮â“....π..“..¬...¢.......‡..®..“â .¢...Õ..ß.. ..“..¡..¬...∑..√..æ—..¬...å .. ‡≈¢ª√–®”μ—«ª√–™“™π ºŸâ...¢..Õ.................................

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Õ“¬ÿ..................................ªï  ≠— ™“μ‘.........................................∫¥‘ “/¡“√¥“™ÕË◊ .............................................................................

‚ ¥ À¡“â ¬ § Ÿà ¡√ ™ËÕ◊ ..........................................................................................

Õ¬àŸ∑Ë’∫“â π/À¡∫àŸ “â π..........................‡≈¢∑Ë’................μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡Ÿà∑’Ë..............

μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®ß— À«—¥.................................À¡“¬‡≈¢‚∑√»æ— ∑.å ....................

Û. ¢â“懮“â .........................›........................ ‡≈¢ª√–®”μ—«ª√–™“™π ºŸ.â ..¢..Õ.................................

................................................
Õ“¬ÿ..................................ªï  —≠™“μ.‘ ........................................∫‘¥“/¡“√¥“™◊ÕË .............................................................................

‚ ¥ À¡“â ¬ § àŸ ¡√ ™Õ◊Ë ....................................................... ≠— ™“μ.‘ ......................
Õ¬∑àŸ Ë∫’ “â π/À¡∫àŸ “â π..........................‡≈¢∑.’Ë ...............μ√Õ°/´Õ¬.......................................∂ππ.....................................À¡àŸ∑Ë’..............
μ”∫≈/·¢«ß...................................Õ”‡¿Õ/‡¢μ...................................®—ßÀ«—¥.................................À¡“¬‡≈¢‚∑√»—æ∑.å ....................

Ù. ¢“â 懮“â ¢Õ· ¥ß√“§“∑√æ— ¬∑å ’¢Ë Õ∑”πμ‘ °‘ √√¡π’‡È ªìπ‡ß‘π.............................›............................∫“∑.........›........... μ“ߧå
ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à

(Ò) ¢â“懮Ⓣ¡à‰¥â√—∫‚Õπ·∑πÀ√◊Õ‡æË◊Õª√–‚¬™πå·°à∫§ÿ §≈μ“à ߥ⓫
(Ú) √“§“∑√—æ¬∑å ·Ë’  ¥ß‰«â„π Ù. ‡ªπì √“§“∑Ë’·∑®â √‘ß
(Û) π...“.¬....¢....‡..®..â“..¢..Õ..ß.. ..“..¡...¬..∑..√..—æ...¬..å.ª...√..–.. ..ß..§...å‡.≈..°‘..√..“..¬...°..“..√..®..¥..∑..–..‡..∫..’¬..π...¿..“..√..–..®..”..¬..Õ..¡...„.π..·...ª..≈..ß.. ...“..¡..¬..∑...√..æ— ..¬..å........................

‡..¡..◊ËÕ..«..π—...∑...Ë’ ..................‡.¥...Õ◊ ..π.......................................æ....».........................∑...ßÈ— ..π..È¿’..“..√..–..®..”..¬..Õ...¡..¬..ß—..§...ß..¡..Õ’..¬...àŸμ..“..¡..‡..¥..‘¡..∑...ÿ°..ª..√..–..°...“.√...................................
(Ù) .....................................................................................................................................................................

«π— ∑.’Ë ...........‡¥Õ◊ π..............................æ.»..................
≈ß™◊ËÕ.....................π..“..¬...¢...........................ºŸâ¢Õ ‡®“â ¢Õß “¡¬∑√æ— ¬å
≈ß™◊ÕË ..........................›............................ºŸâ¢Õ
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‚©π¥∑¥’Ë π‘ „À¡à ª√–∑∫— μ√“
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ÒÙı

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√–‡∫¬’ ∫°√¡∑Ë¥’ π‘

«à“¥â«¬°“√®¥∑–‡∫¬’ π ∑‘ ∏‘·≈–π‘μ°‘ √√¡‡°’¬Ë «°∫— °“√®”πÕß∑¥Ë’ ‘π
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(Ù) ·≈–¢Õâ Ù °. (Òı) (°) ·Àßà °Æ°√–∑√«ß·∫ßà  «à π√“™°“√°√¡∑¥’Ë π‘ °√–∑√«ß

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(Ò) Àπ—ß ◊Õ°√¡∑–‡∫’¬π∑¥’Ë ‘π ≈ß«π— ∑Ë’ ¯ ¡°√“§¡ æ√–æ∑ÿ ∏»—°√“™

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