รวมระเบียบ คำสั่ง เกี่ยวกับการจดทะเบียนสิทธิและนิติกรรมประเภท ก่อภาระผูกพัน และอื่น ๆ (ปี 2552)

°√≥¡’ ’º‡âŸ ™“à À≈“¬§π ºâŸ‡™à“∫“ߧπ‚Õπ ‘∑∏‘°“√‡™à“ μ—«Õ¬à“ßÀ¡“¬‡≈¢ Òı
‡©æ“– à«π¢Õßμπ
 “√∫—≠®¥∑–‡∫’¬π

®¥∑–‡∫¬’ 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◊ ™Õ◊Ë
‚©π¥∑’Ë¥π‘ „À¡à ª√–∑∫— μ√“
‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
«“ «“

«—π∑Ë’................. ‡™à“‡©æ“– «à π Ò. 𓬠°. Ò. 𓬠¢. Ò › › › › › › (≈ß™Õ◊Ë ) 𓬠 .
‡¥Õ◊ π............... (¡’°”Àπ¥ ‘∫ª)ï Ú. 𓬠§.
æ.». ................. Ú. 𓬠®. 𓬠°. „À⇙“à ∑¥Ë’ ‘π‡©æ“– «à π¢Õßμπ·°à

ºŸ‡â ™à“ 𓬠¢. ·≈–𓬠®.  à«π¢Õß∫ÿ§§≈Õπ◊Ë §ß‡¥¡‘

«—π∑Ë.’ ................ ‚Õπ ∑‘ ∏°‘ “√‡™“à Ò. 𓬠¢. Ò. 𓬠ß. Ò › › › › › › (≈ß™ÕË◊ ).........................

‡¥◊Õπ............... ‡©æ“– «à π Ú. π“¢ ®. ºŸâ√—∫‚Õπ 𓬠¢. ‚Õπ ∑‘ ∏‘°“√‡™à“‡©æ“– à«π¢Õßμπ
æ.». ................. ºâ‡Ÿ ™“à Ú. 𓬠®. „Àâ·°à 𓬠ß.  «à π ‘∑∏‘°“√‡™“à ¢Õß∫§ÿ §≈ÕπË◊

ºâŸ‡™“à §ß‡¥‘¡

ÛÙ˘

Ûı

μ«— Õ¬“à ßÀ¡“¬‡≈¢ Òˆ
(∑.¥. ˆ)

Àπ—ß ◊Õ ≠— ≠“‚//Õ/π// //∑‘ //∏//°‘ /“//√/√/—∫//...·...∫..àß..‚..Õ..π... ..‘∑..∏...‘°..“..√..‡.™..à“.....

∑Ë’¥‘π

‚©π¥∑.Ë’ .........................................‡≈¢∑’¥Ë ‘π..........................................Àπâ“ ”√«®.............................................

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

Àπ—ß Õ◊  ≠— ≠“π’ȉ¥∑â ”‡¡◊ËÕ«π— ∑Ë.’ ................‡¥Õ◊ π................................................æ∑ÿ ∏»°— √“™............................................

≥  ”π°— ß“π∑¥’Ë ‘π®ß— À«¥— .................................................... } { }................
º‚⟠Õπ Õ“¬ÿ ......ı.......... ªï
‡≈¢ª√–®”μ—«ª√–™“™π ................

{ }...............................................

√–À«à“ß ...............π...“.¬....¢.........................

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

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

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

{ }............................................... } { }................
º√Ÿâ —∫‚Õπ Õ“¬ÿ ......Û.......... ªï
°∫— ..................π..“..¬....ß...................... ................
...............................................

 ≠— ™“μ.‘ ............‰.∑...¬...................∫¥‘ “/¡“√¥“™ÕË◊ ................................................................................................................................

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

∑—ßÈ  ÕßΩ“É ¬‰¥μâ °≈ß∑” —≠≠“°π— ¥—ßμÕà ‰ªπ’È

¢âÕ Ò. ºâŸ‚Õπ¬Õ¡‚Õπ ‘∑∏‘°“√...‡.™...“à .∫...“..ß.. ..à«..π.......................∑Ë’¥‘π·ª≈ß∑’Ë°≈à“«¢“â ß∫ππ’È ´÷Ëߺ‚⟠Õπ‰¥√â/—∫//....‡.™..à“......................

‰«®â “°....π...“..¬...°...................μ“¡Àπß—  Õ◊  ≠— ≠“....‡.™..“à..∑..Ë’¥...π‘ ..............©∫∫— ∑.’Ë .........≈ß«π— ∑.’Ë .........‡¥Õ◊ π................æ∑ÿ ∏»°— √“™................ππÈ—
·°ºà ‚⟠Õπ‡ªìπ‡¥¥Á ¢“¥μÈß— ·μà«—π∑” —≠≠“πȇ’ ªπì μπâ ‰ª ‚¥¬‡Àμÿ∑º’Ë Ÿ‚â Õπ‰¥.â ..‚..Õ..π..„..À..â·..°..ºà...Ÿ√â ..—∫..‚.Õ...π..¥..â«..¬...§..«..“..¡..‡. ...π..Àà..“....‰.¡..à¡...’§..“à..μ..Õ...∫..·..∑...π...μ...“..¡..√..ªŸ..
·...º..π..∑...ÀË’ ..¡..“..¬... ..’·..¥..ß..·...π..∫..∑...â“..¬..π..È’..‡.π..Ë◊Õ...ß..®..“..°..º..√âŸ..—∫..‚..Õ..π..‡..ª..πì.......................................................¢..Õ..ß..º...Ÿâ‚.Õ..π....®..”..π..«..π...‡.π..ÕÈ◊..∑...∑Ë’ ..·Ë’..∫...ßà ..‚.Õ...π.. ..‘∑..∏...‘°..“..√..‡.™..“à......................................................

¢Õâ Ú. º√Ÿâ ∫— ‚Õπ¬π‘ ¬Õ¡√∫— /‚/Õ/π// /∑‘//∏/°‘//“/√/√/∫—//.....·..∫..ßà..‚..Õ..π.. ..‘∑...∏..°‘..“..√..‡.™...à“..........¥—ß°≈à“«·≈«â „π¢âÕ Ò. πÈπ— ∑ÿ°ª√–°“√ ·≈–‰¥√â —∫

Àπ—ß Õ◊  ≠— ≠“......‡.™..à“..‡.©...æ..“..–.. ..à«..π..................................√“¬π®’È “°ºŸ‚â Õπ‡ √Á®·≈«â

Àπ—ß ◊Õ —≠≠“π’ȉ¥â∑”‡ªìπ “¡©∫—∫¡’¢âÕ§«“¡μ√ß°—π  ”À√—∫ ”π—°ß“π∑Ë’¥‘πÀπË÷ß©∫—∫ ºâŸ√—∫‚Õπ∂◊Õ‰«â©∫—∫Àπ÷Ëß ‡®â“¢Õß

∑Ë¥’ π‘ ∂◊Õ‰«â©∫∫— Àπ÷ßË (©∫∫— π ’È ”À√—∫..............................................................)

∑—ßÈ  ÕßΩÉ“¬‰¥μâ √«®¥ÀŸ π—ß Õ◊  —≠≠“‚/Õ//π/ //‘∑//∏/‘°//“/√/√/∫— /....·..∫...àß..‚.Õ..π... ..∑‘..∏..‘°...“..√..‡.™..à“.........................·≈–‡¢“â „®¢âÕ§«“¡μ≈Õ¥·≈«â

®÷߉¥â≈ß≈“¬¡◊Õ™ÕË◊ À√Õ◊ æ¡‘ æ≈å “¬πÈ‘«¡◊Õ‰«‡â ªì𠔧≠— μÕà Àπ“â 欓π·≈–‡®â“æπ—°ß“π∑Ë’¥‘π
(≈ß≈“¬¡◊Õ™◊Ëպ⟂Õπ)........................π..“..¬....¢....................................
(≈ß≈“¬¡Õ◊ ™Õ◊Ë º√⟠∫— ‚Õπ)....................π..“..¬...ß.....................................

(≈ß≈“¬¡Õ◊ ™◊ËÕ欓π)...................................................................

(≈ß≈“¬¡◊Õ™Ë◊Õ欓π)...................................................................

¢“â 懮“â .........π...“..¬...°...............................................‡®â“¢Õß∑¥Ë’ π‘ ‰¥√⠇⟠ÀπÁ „π°“√‚/Õ//π// /∑‘//∏/°‘//“/√....·..∫..àß..‚..Õ..π.. ...‘∑..∏..‘°..“..√..‡.™...“à ...........

μ“¡Àπ—ß ◊Õ ≠— ≠“©∫∫— π’È·≈«â ·≈–¬Õ¡ªØ∫‘ —μ‘·°àºŸ√â —∫‚ÕπμÕà ‰ª∑°ÿ ª√–°“√
(≈ß≈“¬¡Õ◊ ™Ë◊Õ)...................π..“..¬....°.................................................

Àπß—  ◊Õ ≠— ≠“πÈ’‰¥∑â ”μÕà Àπâ“

.................................................................................‡®“â æπ°— ß“π∑’Ë¥‘π

ª√–∑—∫μ√“μ”·Àπßà ‡ªì𠔧—≠

........................................................ºŸâ‡¢’¬π

........................................................ºŸμâ √«®

▼ ÛıÒ

μ—«Õ¬à“ßÀ¡“¬‡≈¢ Òˆ

·ºπ∑∑’Ë â“¬Àπ—ß Õ◊  ≠— ≠“·∫àß‚Õπ ‘∑∏‘°“√‡™“à
©∫—∫≈ß«—π∑.Ë’ ........‡¥Õ◊ π............................æ.». ....

N ‚©π¥‡≈¢∑Ë.’ .................‡≈¢∑Ë¥’ ‘π....................Àπ“â  ”√«®...............

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

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‡¢μ∑Ë’¥‘π‚©‹π¥‡≈¢∑Ë.’ ............‡ªπì ‡¢μ∑Ë’®¥∑–‡∫’¬π‡™“à ‰«â ‡π◊ÕÈ ∑’Ë Ò ‰√à
111222333444555666777888999000111222 ‡¢μ ’·¥ß ‡ªπì ‡¢μ∑’®Ë ¥∑–‡∫’¬π·∫ßà ‚Õπ ‘∑∏°‘ “√‡™“à ‡πÈ◊Õ∑ª’Ë √–¡“≥ ı ‰√à

≈ß™Õ◊Ë .......................π..“..¬....¢.......................ºŸâ‡™à“
≈ß™Õ◊Ë .......................π..“..¬....ß........................ºâ√Ÿ —∫‚Õπ
≈ß™Õ◊Ë ......................................................欓π
≈ß™ÕË◊ ......................................................欓π
≈ß™ÕË◊ ......................................................‡®â“æπ—°ß“π∑¥Ë’ ‘π

μ«— Õ¬à“ßÀ¡“¬‡≈¢ Òˆ ÛıÚ

 “√∫—≠®¥∑–‡∫¬’ π

®¥∑–‡∫¬’ π ª√–‡¿∑°“√ ºâŸ„À â ≠— ≠“ ºâŸ√—∫ —≠≠“ ‡πÈ◊Õ∑Ë’¥‘π ‡πÈ◊Õ∑Ë’¥‘π √–«“ß ‡®â“æπ—°ß“π∑’Ë¥‘π
«π— ‡¥◊Õπ ªï ®¥∑–‡∫¬’ π 𓬠°. μ“¡ ≠— ≠“ §ß‡À≈Õ◊ ‡≈¢∑Ë’¥‘π ≈ß≈“¬¡Õ◊ ™ÕË◊
𓬠¢. ‚©π¥∑Ë’¥π‘ „À¡à ª√–∑∫— μ√“
«—π∑Ë.’ ................ ‡™“à ºâŸ‡™à“ ‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
‡¥◊Õπ............... (¡’°”Àπ¥ ∫‘ ªï) «“ «“
æ.». .................
Ò › › › › › › (≈ß™ÕË◊ ) 𓬠 .

«—π∑Ë.’ ................ ·∫àß‚Õπ ‘∑∏‘°“√‡™à“ 𓬠¢. Ò. 𓬠ß. Ò › › › › › › (≈ß™ÕË◊ ).........................

‡¥Õ◊ π............... ºŸâ‡™“à º√⟠∫— ‚Õπ

æ.». ................. Ú. 𓬠¢.

ºŸâ‡™“à

μ«— Õ¬à“ßÀ¡“¬‡≈¢ Ò˜ ÛıÛ

(∑.¥. Ò)
∑∫Ë’ “â π

∑Ë ’ «π/‰√à

∑Ë’π“

∑Ë.’ .............

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

„π‡¢μ

·≈–°“√ Õ∫ «π ∑‘ ∏‘„π∑¥’Ë ‘π ª√–‡¿∑...·..∫..àß..‚..Õ..π.. ...‘∑..∏..‘°..“..√..‡..™..à“..‡.©..æ...“.–... ..«à ..π........

μ”·Àπàß∑’Ë¥‘π

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

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

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

𓬠¢. ‚Õπ ‘∑ ‘∏°“√‡™à“‡©æ“– à«π¢Õßμπ‡æ’¬ß∫“ß à«π „Àâ·°à 𓬠ß. μ“¡ —≠≠“‡™à“‡©æ“– à«π ©∫—∫≈ß«—π∑’Ë.......................‚©π¥∑’Ë¥π‘
‡®â“æπ—°ß“π Ë’∑ ‘¥π ‡≈¢∑Ë’.....................Ò..Ú...Û..................‡≈à¡............Ò..Û..........................Àπ“â ............Û........................

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

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

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

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

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

‚ ¥ 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...................................®—ßÀ«—¥.................................À¡“¬‡≈¢‚∑√»—æ∑.å ....................

Û. ¢“â 懮“â ...............Ò.....π..“..¬....ß....................... ‡≈¢ª√–®”μ—«ª√–™“™π ºŸ.â ..√..—∫...‚.Õ..π...........................

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

‚ ¥ À¡“â ¬ § Ÿà ¡√ ™ÕË◊ ....................................................... —≠™“μ‘.......................

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

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

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

ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à (Àâ“À¡πË◊ ∫“∑∂«â π)

(Ò) ¢“â 懮Ⓣ¡à‰¥√â ∫— ‚Õπ·∑πÀ√Õ◊ ‡æÕ◊Ë ª√–‚¬™πå·°∫à ÿ§§≈μà“ߥ“â «

(Ú) √“§“∑√æ— ¬å∑·’Ë  ¥ß‰«â„π Ù. ‡ªìπ√“§“∑Ë’·∑®â √ß‘
(Û) .·..∫..àß..‚..Õ..π.. ...∑‘ ..∏..°‘..“..√..‡.™...à“.„..À..¥â..â«..¬...§..«..“..¡..‡. ...π..Àà..“....‰.¡..¡à...§’ ..à“..μ..Õ...∫..·..∑...π...μ...“..¡..√..ªŸ..·...º..π..∑...’ÀË ..¡..“..¬.. ...‡’ .¢..’¬..«..·...π..∫..∑...“â .¬...π..’È..‡.π..Ë◊Õ..ß..®...“.°...º..â√Ÿ..—∫..‚.Õπ

.‡.ª..πì......................¢..Õ..ß..º...Ÿâ‚.Õ..π....‡.ª...ìπ..°..“..√..·..∫...ßà ..‚.Õ...π.. ..‘∑..∏...‘°..“..√..‡.™..“à..μ..“..¡... ..—≠...≠...“..‡.™...à“.∑...¥’Ë ..π‘..‡..©..æ...“.–.. ...à«..π...©...∫..∫—...≈..ß..«..—π..∑..’.Ë........‡.¥...Õ◊ ..π....................æ....».... ....
(Ù) .®..”.π...«..π..‡.π...◊ÈÕ..∑..’∑Ë...Ë’·..∫..àß..‚..Õ..π.. ...‘∑..∏..‘°..“..√..‡.™...à“..‡.©..æ...“.–.. ...à«..π..................................................................................................................................

«π— ∑.Ë’ ...........‡¥Õ◊ π..............................æ.»..................
≈ß™◊ÕË .....................π...“.¬....¢.........................ºŸâ¢Õ ‡™à“
≈ß™ËÕ◊ .....................π...“..¬...ß..........................ºâŸ¢Õ √—∫‚Õπ

≈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..........5..1..3.6....I.V....7..2..2..8..›..1..........‡≈¢∑¥’Ë π‘ .................Ò..............................Àπ“â  ”√«®...........Ú..............................

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

®”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™◊ËÕ.......................................................

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

‡®â“æπ—°ß“π∑Ë’¥‘π

ÛıÙ

μ«— Õ¬“à ßÀ¡“¬‡≈¢ Ò˜
(∑.¥. ˆ)

Àπ—ß ◊Õ ≠— ≠“‚//Õ/π// //∑‘ //∏/°‘//“//√/√/—∫//...·...∫..ßà..‚..Õ..π.. ...∑‘ ..∏..°‘...“..√..‡.™..“à..‡.©...æ..“..–.. ...«à ..π....

∑’Ë¥‘π

‚©π¥∑.Ë’ .........................................‡≈¢∑’Ë¥‘π..........................................Àπ“â  ”√«®.............................................

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

Àπß—  Õ◊  —≠≠“πÈ’‰¥â∑”‡¡Ë◊Õ«—π∑.’Ë ................‡¥◊Õπ................................................æ∑ÿ ∏»—°√“™............................................

≥  ”π—°ß“π∑¥Ë’ ‘π®ß— À«¥— .................................................... } { }................
ºâŸ‚Õπ Õ“¬ÿ ......ı.......... ªï
‡≈¢ª√–®”μ—«ª√–™“™π ................

{ }...............................................

√–À«à“ß ...............π...“.¬....¢.........................

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

 ≠— ™“μ.‘ ...................................∫‘¥“/¡“√¥“™◊ÕË ...............................................................................................................................

Õ¬Ÿ∑à ∫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 .........................
‡≈¢ª√–®”μ—«ª√–™“™π

{ }............................................... } { }................
º√Ÿâ ∫— ‚Õπ Õ“¬ÿ ......Û.......... ªï
°∫— ..................π..“..¬....ß......................
............................................... ................

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

Õ¬àŸ∑∫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 ..........................

∑—ßÈ  ÕßΩ“É ¬‰¥μâ °≈ß∑” —≠≠“°π— ¥ß— μÕà ‰ªπÈ’

¢âÕ Ò. ºâŸ‚Õπ¬Õ¡‚Õπ ∑‘ ∏‘°“√..‡.™..“à..‡.©...æ..“..–.. ..«à..π..¢...Õ..ß..μ..π...‡.æ..’¬...ß..∫..“..ß.. ..à«..π....∑’Ë¥π‘ ·ª≈ß∑’Ë°≈“à «¢“â ß∫ππÈ’ ´Ëß÷ ºâŸ‚Õπ‰¥/â√/—∫/...‡.™..à“........

‰«®â “°.....π...“.¬....°.........μ“¡Àπß—  Õ◊  ≠— ≠“..‡..™..à“..∑..’Ë¥..π‘...‡.©..æ...“..–.. ..«à..π...........©∫∫— ∑.’Ë .........≈ß«π— ∑.’Ë .........‡¥Õ◊ π................æ∑ÿ ∏»°— √“™............ππÈ—
·°àº‚⟠Õπ‡ªìπ‡¥¥Á ¢“¥μß—È ·μ«à —π∑” —≠≠“π‡’È ªπì μπâ ‰ª ‚¥¬‡Àμ∑ÿ º’Ë ‚Ÿâ Õπ‰¥.â ..‚..Õ..π..„..À..·â..°..ºà...√⟠..—∫..‚.Õ...π..¥...«â .¬...§..«..“..¡..‡.. ..π..Àà..“....‰.¡..¡à...§’ ..à“..μ..Õ...∫..·..∑...π...μ...“..¡..√..ªŸ..
·...º..π..∑...À’Ë ..¡..“..¬... ..’‡.¢..’¬...«.·...π..∫..∑...â“..¬..π..È’..‡.π..◊ÕË...ß..®..“..°..º..â√Ÿ..—∫..‚..Õ..π..‡..ª..πì...........................................¢..Õ..ß..º..Ÿâ‚..Õ..π....®..”..π..«..π..‡..π..ÈÕ◊..∑...’Ë∑..’·Ë..∫...ßà ..‚.Õ..π... ..‘∑..∏..°‘...“..√..‡.™..à“..‡.©..æ...“..–.. ..à«..π........................................

¢Õâ Ú. º√⟠—∫‚Õπ¬π‘ ¬Õ¡√∫— /‚/Õ/π// /‘∑//∏/‘°//“/√/√/∫—//.....·..∫..àß..‚..Õ..π.. ..∑‘...∏..°‘..“..√..‡.™...“à .‡..©..æ..“..–.. ...à«..π...........¥ß— °≈“à «·≈â«„π¢âÕ Ò. ππ—È ∑°ÿ ª√–°“√

·≈–‰¥√â ∫— Àπ—ß ◊Õ ≠— ≠“..............›.............................................√“¬π®È’ “°ºâŸ‚Õπ‡ √®Á ·≈â«

Àπ—ß ◊Õ —≠≠“π’ȉ¥â∑”‡ªìπ “¡©∫—∫¡’¢âÕ§«“¡μ√ß°—π  ”À√—∫ ”π—°ß“π∑Ë’¥‘πÀπË÷ß©∫—∫ ºâŸ√—∫‚Õπ∂◊Õ‰«â©∫—∫Àπ÷Ëß ‡®â“¢Õß

∑Ë’¥π‘ ∂Õ◊ ‰«©â ∫—∫Àπß÷Ë (©∫∫— π È’ ”À√∫— ..............................................................)

∑ß—È  ÕßΩÉ“¬‰¥μâ √«®¥ŸÀπ—ß ◊Õ ≠— ≠“‚/Õ//π/ //‘∑//∏/°‘ /“//√/√/∫— /....·..∫...ßà ..‚.Õ..π... ..‘∑..∏..‘°...“..√..‡.™..“à..‡.©..æ...“..–.. ..à«..π.........·≈–‡¢â“„®¢âÕ§«“¡μ≈Õ¥·≈«â

®ß÷ ‰¥â≈ß≈“¬¡◊Õ™Ë◊ÕÀ√Õ◊ æ‘¡æå≈“¬π‘È«¡Õ◊ ‰«‡â ªì𠔧≠— μàÕÀπ“â 欓π·≈–‡®â“æπ—°ß“π∑’¥Ë π‘
(≈ß≈“¬¡◊Õ™◊Ëպ₟ Õπ)........................π..“..¬....¢....................................
(≈ß≈“¬¡Õ◊ ™ÕË◊ º√Ÿâ ∫— ‚Õπ)....................π..“..¬....ß....................................

(≈ß≈“¬¡Õ◊ ™ËÕ◊ 欓π)...................................................................

(≈ß≈“¬¡Õ◊ ™Õ◊Ë æ¬“π)...................................................................

¢“â 懮“â ..........π..“..¬....°...............................‡®â“¢Õß∑¥Ë’ π‘ ‰¥√⠇⟠ÀπÁ „π°“√‚/Õ//π/ //∑‘ //∏/°‘ /“//√......·..∫...ßà ..‚.Õ..π... ..‘∑..∏..°‘...“.√..‡..™..à“..‡.©..æ...“..–.. ..«à..π.........

μ“¡Àπß—  Õ◊  —≠≠“©∫—∫π·’È ≈«â ·≈–¬Õ¡ªØ∫‘ —μ‘·°àºŸ√â ∫— ‚ÕπμàÕ‰ª∑ÿ°ª√–°“√
(≈ß≈“¬¡Õ◊ ™ËÕ◊ )...................π..“..¬....°.................................................

Àπß—  ◊Õ —≠≠“πÈ’‰¥â∑”μÕà Àπ“â

.................................................................................‡®“â æπ—°ß“π∑¥’Ë ‘π

ª√–∑—∫μ√“μ”·Àπà߇ªì𠔧≠—

........................................................º‡âŸ ¢’¬π

........................................................ºŸâμ√«®

Ûıı

▼ μ«— Õ¬“à ßÀ¡“¬‡≈¢ Ò˜

·ºπ∑Ë∑’ “â ¬Àπß—  Õ◊  ≠— ≠“·∫ßà ‚Õπ ∑‘ ∏°‘ “√‡™à“‡©æ“– «à π
©∫∫— ≈ß«π— ∑’.Ë ........‡¥◊Õπ............................æ.». ....

N ‚©π¥‡≈¢∑Ë.’ .................‡≈¢∑’¥Ë ‘π....................Àπ“â  ”√«®...............

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

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‡¢μ∑’¥Ë ‘π‚©π‹ ¥‡≈¢∑Ë.’ ............ ‡π◊ÕÈ ∑’Ë Ò ‰√à
111222333444555666777888999000111 ‡¢μ ·’ ¥ß ‡ªìπ‡¢μ∑’Ë®¥∑–‡∫¬’ π‡™“à ‡©æ“– «à π‰«â ‡πÈÕ◊ ∑’ªË √–¡“≥ ı ‰√à

111122223333444455556666777788889999000011112222333344445555666677778888 ‡¢μ ‡’ ¢’¬« ‡ªπì ‡¢μ∑®’Ë ¥∑–‡∫’¬π·∫àß‚Õπ ∑‘ ∏‘°“√‡™à“‡©æ“– «à π ‡πÕ◊È ∑Ë’ª√–¡“≥ Û ‰√à

≈ß™ÕË◊ .......................π..“..¬....¢.......................ºŸâ‡™à“
≈ß™Õ◊Ë .......................π..“..¬....®........................º√⟠∫— ‚Õπ
≈ß™ÕË◊ ......................................................欓π
≈ß™ÕË◊ ......................................................欓π
≈ß™Õ◊Ë ......................................................‡®“â æπ°— ß“π∑’Ë¥‘π

μ«— Õ¬“à ßÀ¡“¬‡≈¢ Ò˜ Ûıˆ

 “√∫≠— ®¥∑–‡∫¬’ π

®¥∑–‡∫’¬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
Ò. 𓬠°. 𓬠¢. ‚©π¥∑¥Ë’ π‘ „À¡à ª√–∑∫— μ√“
«—π∑.Ë’ ................ ‡™à“‡©æ“– à«π Ú. 𓬠§. º‡âŸ ™“à ‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
‡¥◊Õπ............... (¡°’ ”Àπ¥ ∫‘ ª)ï «“ «“
æ.». .................
Ò › › › › › › (≈ß™◊ËÕ) 𓬠 .

𓬠°. „À‡â ™à“∑Ë¥’ π‘ ‡©æ“– «à π¢Õßμπ·°à
𓬠¢.  à«π¢Õß∫ÿ§§≈ÕË◊π§ß‡¥‘¡

«π— ∑’.Ë ................ ·∫àß‚Õπ ∑‘ ∏‘°“√‡™“à 𓬠¢. Ò. 𓬠ß. Ò › › › › › › (≈ß™◊ËÕ).........................

‡¥◊Õπ............... ‡©æ“– «à π ºŸ‡â ™“à ºâ√Ÿ —∫‚Õπ 𓬠¢. ‚Õπ ‘∑∏‘°“√‡™“à ‡©æ“– «à π¢Õßμπ

æ.». ................. Ú. 𓬠¢. ‡æ’¬ß∫“ß à«π„À·â °à 𓬠ß. μ“¡ —≠≠“‡™“à
ºŸ‡â ™“à ‡©æ“– à«π ©∫∫— ≈ß«π— ∑Ë’...............................

μ«— Õ¬à“ßÀ¡“¬‡≈¢ Ò¯ Ûı˜

(∑.¥. Ò)
∑∫’Ë “â π

∑Ë ’ «π/‰√à

∑’Ëπ“

∑’Ë..............

§”¢Õ®¥∑–‡∫’¬π ‘∑∏‘·≈–π‘μ‘°√√¡ πÕ°‡¢μ

„π‡¢μ

·≈–°“√ Õ∫ «π ∑‘ ∏‘„π∑Ë’¥π‘ ª√–‡¿∑...‚.Õ..π...¡..√..¥..°... ..∑‘..∏..‘°...“..√..‡.™..à“......................

μ”·Àπàß∑’Ë¥‘π

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

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

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

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

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

Ò. ¢â“æ‡®â“ºâŸ¡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ⓄÀâ∂Õâ ¬§”‰¡à‡ªπì §«“¡®√ß‘ „Àâ„™∂â âÕ¬§”πȬ’ —π¢“â 懮“â „π∑“ߧ¥Õ’ “≠“‰¥â

Ú. ¢“â 懮“â ..............π..“..¬...¢......(.μ..“..¬...)............... ‡≈¢ª√–®”μ—«ª√–™“™π ºâ.Ÿ ..‡.™..“à................................

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

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

Õ¬Ÿ∑à 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..“..¬....ß........................... ‡≈¢ª√–®”μ—«ª√–™“™π ºŸâ...√..∫—...¡..√..¥..°... ..‘∑..∏..°‘...“.√..‡..™..à“.....

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

‚ ¥ À¡“â ¬ § Ÿà ¡√ ™Ë◊Õ....................................................... —≠™“μ‘.......................

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

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

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

ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à (Àπ÷Ëß· π∫“∑∂â«π)

(Ò) ¢“â 懮“â ‰¡à‰¥â√∫— ‚Õπ·∑πÀ√Õ◊ ‡æË◊Õª√–‚¬™π·å °à∫§ÿ §≈μà“ߥ⓫

(Ú) √“§“∑√æ— ¬å∑’·Ë  ¥ß‰«â„π Ù. ‡ªìπ√“§“∑’Ë·∑®â √‘ß
(Û) .∑..¥Ë’ ..‘π...·..ª..≈...ß..π..È’ .π...“..¬...¢.....‡.ª..ìπ...º..⇟ .™..à“..μ...“.¡... ..—≠...≠...“..‡..™..“à ..∑..¥Ë’..π‘...©..∫..—∫...≈..ß..«..π—..∑...’Ë ........‡.¥..Õ◊...π..............æ...»..........¡..’°...”.À...π..¥.............ª..ï..´..ßË÷..√..–..∫..ÿ.

.„.À..â ...‘∑..∏..°‘..“..√..‡.™...“à . ...“..¡..“..√..∂..μ..°...∑..Õ..¥...‡.ª..ìπ...¡..√..¥..°...‰.¥..â....................................................................................................
(Ù) .¢..“â ..æ..‡.®..“â..‡..ª..πì ..º...Ÿâ√..∫— ..¡..√..¥...°.. ..‘∑...∏..‘°..“..√..‡.™..à“..μ..“..¡...æ..‘π..¬—...°..√..√..¡....©..∫..—∫...≈..ß..«..π—..∑...Ë’.......‡.¥..Õ◊...π..............æ....»..............‚..¥..¬..‡..ª..ìπ..∫...ÿμ..√..¢..Õ...ß...π..“..¬....¢.....º...⟇.™“à

(ı) 𓬠¢. ∂ß÷ ·°°à √√¡‡¡ÕË◊ «π— ∑Ë’.....‡¥Õ◊ π.............æ.». .... «π— ∑.’Ë ...........‡¥Õ◊ π..............................æ.»..................

μ“¡„∫¡√≥∫—μ√‡≈¢∑’Ë.......................... ≈ß™◊ËÕ..........................›............................ºŸâ¢Õ ‡™“à

≈ß™ËÕ◊ .....................π...“..¬...ß..........................ºŸâ¢Õ √—∫¡√¥° ‘∑∏°‘ “√‡™“à

≈ß™◊ËÕ......................................................º âŸ 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..............................Àπ“â  ”√«®...........Ú..............................

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

®”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

Ûı¯

μ«— Õ¬“à ßÀ¡“¬‡≈¢ Ò¯

(∑.¥. ¯)

·∫∫∫π— ∑÷°°“√ Õ∫ «π¢Õ®¥∑–‡∫¬’ π‚Õπ¡√¥°
∑Ë’¥‘π ª√–‡¿∑....‚.Õ..π...¡..√..¥...°.. ..‘∑...∏..°‘..“..√..‡..™..“à ..................

√–«“ß.................................................................................μ”∫≈..............................................................................
‡≈¢∑’.Ë ................................................Àπâ“ ”√«®............................................Õ”‡¿Õ.................................................

}‚©π¥

π. .Û ‡≈¢∑.Ë’ ...................................................................®ß— À«—¥.....................................................................
„∫‰μà «π

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

‡≈¢ª√–®”μ—«ª√–™“™π

{ }............................................... } { }................
Õ“¬ÿ ......Û.......... ªï
√–À«à“ß ..................π..“..¬....ß...................... ................
...............................................
 —≠™“μ.‘ ..............‰.∑...¬.................∫¥‘ “/¡“√¥“™◊ÕË ...............................................................................................................................

Õ¬∑Ÿà ∫’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 .........................
¢Õ„Àâ∂âÕ¬§”μàÕ.......‡.®..“â..æ...π..°—..ß..“..π..∑...Ë’¥..π‘...®..ß— ..À..«..—¥...............................................................¥ß— μàÕ‰ªπÈ’

¢Õâ Ò. ¥«â ¬..........π..“..¬....¢.......................................................................................... ≠— ™“μ.‘ .....‰.∑...¬................................
´Ëß÷ ‡ªìπ......º..⟇..™..à“..................................................................∑’Ë¥‘π·ª≈ßÀ¡“¬‡≈¢¢â“ßμπâ πÈ’‰¥.â ....∂..÷ß..·...°..à°..√..√..¡..........................................
‡¡Õ◊Ë ..........«..π—..∑....’Ë ..................‡.¥...Õ◊ ..π.......................................æ....»..................μ“¡À≈°— ∞“π...„.∫...¡..√..≥...∫...—μ..√..‡.≈...¢..∑..Ë.’......................©..∫...—∫..≈...ß..«..—π..∑..’Ë....................................´ßË÷ ‰¥¬â π◊Ë ¡“æ√Õâ ¡π·È’ ≈«â

¢Õâ Ú. Àπß—  Õ◊ · ¥ß ‘∑∏‘„π∑’Ë¥‘π·ª≈ßπ’È ‡«≈“πμÈ’ °Õ¬Ÿ°à ∫— ......π...“.¬....°......º..⟄.À...‡â .™..à“....´..Ë÷ß..‰.¥..âπ...”..¡..“..¬..Ë◊π..æ...√..Õâ ..¡...§..”..¢..Õ..π...’È ...................

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¢Õâ Û. ¢“â 懮ⓢՄÀ⥔‡π‘π°“√®¥∑–‡∫’¬π¡√¥°≈ß™Õ◊Ë ..........¢...“â .æ...‡.®..“â..‡.ª...πì ..º..â√Ÿ..—∫...¡..√..¥...°.. ..∑‘..∏...°‘ ..“..√..‡.™..à“..∑..Ë¥’...‘π..·..ª...≈..ß..π..’Èμ...Õà ..‰.ª..........

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‚¥¬‡Àμºÿ ≈¥—ßπ’ȧÕ◊ ....¢..â“..æ..‡..®..“â .‡..ª..ìπ..∫...μÿ ..√....π..“..¬....¢.....º..Ÿâ‡.™...à“.∑...’Ë¥..π‘...·..ª..≈..ß...π..’È .¡...°’ ..”..À..π..¥..................ª...ï .(..μ..ß—È ..·..μ...«à .π—...∑..Ë’................‡.¥..◊Õ...π................................æ....»..............∂..ß÷..«..—π..∑...’Ë...................
‡..¥..◊Õ..π.............................................æ....»............)...‚.¥...¬..√..–..›∫...ÿ„.π.. ..—≠....≠...“..‡.™..“à..¡..’°...”.À...π..¥...........................ª..ï..¢..Õâ .........................«..“à ...ç..„.π..√..–..À...«..à“.ß..°...“..√..‡.™..“à..∂..â“..Ω..“É..¬..À...π..Ëß÷..Ω..“É..¬..„..¥..∂..ß÷..·...°..à°..√..√..¡..≈...ß..
 ...—≠...≠...“..π..È’‚..Õ..π..„..À..âº..â√Ÿ..∫—...¡..√..¥...°..μ..°..∑...Õ..¥...¥..”..‡.π..‘π...°..“..√..μ..“..¡.. ...≠— ...≠...“..π..Èμ’...Õà ..‰.ª...‰.¥..éâ...π...“.¬....¢.....‰..¥..â∂..ß÷..·...°..à°..√..√..¡...‡.¡..◊ËÕ..«..—π...∑...Ë’..................‡..¥..Õ◊ ..π................................................æ....»................
.‚.¥..¬..‰..¥..∑â...”.æ...‘π..¬—..°...√..√..¡..¬..°... ..‘∑..∏..°‘...“.√..‡..™..“à ..„.À..â·...°..à¢..“â..æ..‡..®..â“...ª..√..“..°..Ø...μ..“..¡..æ...‘π..—¬..°...√..√..¡..©..∫...∫— ..≈..ß..«..π—...∑..’.Ë...............‡.¥..Õ◊...π................................æ....»..............´..÷Ëß..‰.¥...¬â ..◊Ëπ..¡...“..æ..√..âÕ..¡...°..—∫....
.§..”..¢..Õ..π...’È·..≈..â«.....................................................................................................................................................................................

¢Õâ Ù. .....................................................................................................................................................................

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¢â“懮“â ¢Õ√—∫√Õß«“à ∂âÕ¬§”π’ȇªπì §«“¡ —μ¬å®√‘ß∑°ÿ ª√–°“√

À¡“¬‡Àμÿ Ò. §”¢ÕπÈ’‰¡àμÕâ ß· ¥ß∫≠— ™’‡§√Õ◊ ≠“μ‘ }(≈ß™ÕË◊ )...........................π...“.¬....ß..............................
‡πËÕ◊ ß®“°‡ªπì °“√√∫— ¡√¥° ∑‘ ∏‘°“√‡™“à
‚¥¬æ‘π¬— °√√¡ (≈ß™ËÕ◊ )................................................................ ºŸâ„À∂â Õâ ¬§”
(≈ß™◊ËÕ)................................................................
Ú. μâÕß¡°’ “√ª√–°“»¡√¥°¥«â ¬ (≈ß™ÕË◊ )................................................................º âŸ Õ∫ «π/∫π— ∑°÷

μÕà Àπ“â ...........................................................................æπ°— ß“π‡®“â Àπ“â ∑’Ë

μ«— Õ¬à“ßÀ¡“¬‡≈¢ Ò¯

 “√∫—≠®¥∑–‡∫¬’ π

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

«π— ∑Ë.’ ................ ‡™à“ 𓬠°. Ò › › › › › › (≈ß™◊ËÕ) 𓬠 .

‡¥◊Õπ............... (¡’°”Àπ¥............ªï)

æ.». .................

«—π∑Ë.’ ................ ‚Õπ¡√¥° 𓬠¢. 𓬠ß. Ò › › › › › › (≈ß™◊ËÕ).........................
‡¥◊Õπ...............  ∑‘ ∏‘°“√‡™à“ ºâ‡Ÿ ™à“ (쓬) ºâ√Ÿ ∫— ‚Õπ¡√¥°
æ.». .................  ∑‘ ∏°‘ “√‡™“à

Ûı˘

Ûˆ

μ«— Õ¬à“ßÀ¡“¬‡≈¢ Ò˘ (∑.¥. Ò)

∑∫’Ë “â π

∑’ Ë «π/‰√à

∑’Ëπ“

∑Ë.’ .............

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

„π‡¢μ

·≈–°“√ Õ∫ «π ‘∑∏‘„π∑’Ë¥‘π ª√–‡¿∑...·..°..â.‰.¢..‡.æ...‘Ë¡..‡.μ...‘¡.. ..≠—....≠...“..‡.™..“à...................

μ“¡ —≠≠“‡™à“ Ë’∑¥‘π©∫—∫≈ß«—π∑’Ë...........‡¥◊Õπ..................æ.». .... ∫—¥ ’πÈ §àŸ —≠≠“∑—Èß ÕßΩÉ“¬‰¥âμ°≈߇æË‘¡‡μ‘¡¢âÕ§«“¡„π¢âÕ Ù ·Ààß — ≠≠“‡™à“‡¥‘¡μ”·Àπàß∑’Ë¥‘π
ª√“°Øμ“¡∫—π ÷∑° â¢Õμ°≈ß·°â‰¢‡æ‘Ë¡‡μ‘¡ —≠≠“‡™à“ ©∫—∫≈ß«—π∑’Ë...........‡ ◊¥Õπ..................æ.». ....
√–«“ß......................................................................................... μ”∫≈.........................................................................................
‡ â®“æ —π°ß“π ’Ë∑¥‘π
‡≈¢∑’Ë¥‘π..................................................................................... Õ”‡¿Õ........................................................................................

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

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

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

Ò. ¢â“懮⓺Ÿ¡â 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∂âÕ¬§”¥â«¬§«“¡ —쬮å √ß‘ ∂â“¢â“懮“â „À∂â 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 ºŸ.â ..„.À...‡â .™..“à............................

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

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

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

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

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

‚ ¥ À¡“â ¬ §Ÿà ¡√ ™ËÕ◊ ....................................................... —≠™“μ‘.......................

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

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

ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à (À“â À¡π◊Ë ∫“∑∂«â π)

(Ò) ¢â“懮“â ‰¡à‰¥√â ∫— ‚Õπ·∑πÀ√Õ◊ ‡æËÕ◊ ª√–‚¬™πå·°à∫ÿ§§≈μà“ߥ“â «

(Ú) √“§“∑√—æ¬å∑·’Ë  ¥ß‰«â„π Ù. ‡ªìπ√“§“∑Ë’·∑®â √ß‘
(Û) .º..⟄.À...‡â .™..à“..·..≈...–..º..‡âŸ.™..à“..‰..¥..âμ..°...≈..ß..·..°..â.‰.¢..‡..æ..‘¡Ë..‡..μ..¡‘.. ...—≠...≠...“..‡.™..à“....©..∫..—∫...«..—π..∑...’Ë ..........‡.¥..◊Õ...π........................æ....».........................................

(Ù) .....................................................................................................................................................................

(ı) .....................................................................................................................................................................

«π— ∑.Ë’ ...........‡¥Õ◊ π..............................æ.»..................
≈ß™◊ËÕ.....................π...“.¬....°.........................ºŸâ¢Õ „À‡â ™“à
≈ß™Ë◊Õ.....................π...“.¬....¢..........................ºŸâ¢Õ ‡™“à

≈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“ ”√«®...........Ú..............................

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

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

≈ß™◊ËÕ.......................................................

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

‡®â“æπ—°ß“π∑’Ë¥‘π

μ—«Õ¬à“ßÀ¡“¬‡≈¢ Ò˘ ÛˆÒ

(∑.¥. Òˆ)

∫—π∑÷°¢âÕμ°≈ß·°â‰¢‡æ‘Ë¡‡μ‘¡ ≠— ≠“‡™à“

∑’Ë¥‘π
√–«“ß.............5..1..3.6....I.V....7..2..2..8..›..1..........................................μ”∫≈........................................................................
‡≈¢∑’Ë¥‘π..................Ú..Û...........Àπ“â  ”√«®..........Ù..Ù................Õ”‡¿Õ.......................................................................
‚©π¥À¡“¬‡≈¢∑Ë.’ ..............ı..Û...˘..Ò.........................................®ß— À«—¥.......................................................................

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

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

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

.....................π..“..¬....¢.......º..Ÿâ‡.™..à“..........................................................

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

Õ¬Ÿ∑à ’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/àÕ//.....‰..¥..∑â...”.∫...—π..∑..÷°...¢..âÕ..μ...°..≈..ß..μ..Õà...‡.®..“â..æ..π...—°..ß..“..π..∑...¥’Ë ..‘π.....................................................................................

¥//â«//¬//§//«/“/¡// //μ—//¬//å®/√//‘ß/ ¥—ßμÕà ‰ªπ’È :›
......................¢..Õâ....Ò......¥...«â ..¬..¢...â“..œ...π...“..¬....°....º...Ÿâ„.À...‡â .™...“à ...·..≈...–..¢..â“..œ....π..“..¬....¢.....º..⇟..™..“à...‰..¥..∑â...”.. ..≠—....≠...“..‡.™...à“..∑..Ë¥’...‘π....©..∫...—∫..≈...ß..«..π—..∑...’Ë ......‡.¥..◊Õ...π....................æ...»............
∫...¥—...π..È’..¢..â“..œ....∑..ß—È.. ...Õ..ß..Ω...É“..¬..‰.¥...μâ...°..≈..ß...‡.æ...‘Ë¡..‡.μ...‘¡..¢...Õâ ..§...«..“..¡..„..π..¢..Õâ....Ù....·...À..ßà.. ...≠— ...≠....“..‡.™..“à..∑...¥’Ë ..‘π....«..à“....................................................................................
......................ç..„.π...√..–..À..«..“à..ß...°..“..√..‡.™...“à ..∂..“â..º..‡âŸ..™..à“..∂..÷ß...·..°..°à...√..√..¡..≈...ß...„..À..â ...≠— ...≠....“..‡.™..“à..∑...’¥Ë ..π‘...π..’È‚..Õ..π...„.À..·â...°..ºà...√⟠..∫— ..¡...√..¥..°...μ..°...∑..Õ...¥..¢...Õ..ß..º...‡âŸ .™..“à..¡...’ ..‘∑...∏..‘μ..“..¡... ..≠—....≠...“..π..’È
μ...Õà ..‰..ª..‰..¥..éâ....................................................................................................................................................................................................
......................¢..âÕ....Ú.......¢...“â ..œ...∑...—Èß.. ..Õ...ß..Ω..É“..¬...®..ß÷..¢..Õ...„.À...‡â .®..“â..æ...π..—°...ß..“..π..∑...Ë¥’..π‘...®..¥...∑..–..‡..∫..¬’...π..·..°...â‰..¢..‡.æ...Ë‘¡..‡..μ..¡‘... ..≠—....≠...“..‡.™...“à ..„.À..âª...√..“..°..Ø...‡.ª...πì ..À...≈..°—...∞..“..π..¥...â«..¬...........
......................∫...π— ..∑...÷°..¢..Õâ...μ..°...≈..ß..π...’È∑..”..¢..Èπ÷...À..π...÷Ëß..©..∫...∫—....‡.°...∫Á ..‰..«..â .≥..... ...”..π..—°...ß..“..π..∑...’¥Ë ..‘π....¢..â“..œ....∑...Èß— .. ..Õ...ß..Ω..“É..¬...‰.¥...μâ ..√..«..®..∫...π—...∑..÷°..¢...Õâ ..μ...°..≈..ß...π..’È..·..≈..–...‡.¢..“â..„..®............
.¢..Õâ ..§...«..“..¡..μ...≈..Õ...¥..·...≈..â«....®..ß÷ ..≈..ß...≈..“..¬..¡...Õ◊ ..™...◊ÕË ..‰..«..‡â .ª...πì ..À..≈...°—..∞...“.π...μ..Õà...À..π...â“..æ..¬...“..π..·...≈..–..‡..®..â“..æ..π...—°..ß..“..π...∑..Ë¥’...π‘ ..........................................................................

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............................................................................................≈..ß...™..◊ËÕ...........................................................π......“....¬.........°......................................................º..Ÿâ.„.À...‡â .™..“à........................................
............................................................................................≈..ß...™..◊ËÕ...........................................................π......“....¬.........¢......................................................º..Ÿâ‡..™..à“............................................
............................................................................................≈..ß...™..◊ËÕ....................................................................................................................................æ...¬..“..π...........................................
............................................................................................≈..ß...™..◊ËÕ.....................................................................................................................................æ...¬..“..π...........................................
.............................∫...π— ..∑...÷°..¢..âÕ...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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μ—«Õ¬à“ßÀ¡“¬‡≈¢ Ò˘ ÛˆÚ

 “√∫≠— ®¥∑–‡∫¬’ π

®¥∑–‡∫’¬π ª√–‡¿∑°“√ ºŸâ„À â ≠— ≠“ ºâŸ√—∫ —≠≠“ ‡πÈ◊Õ∑’Ë¥‘π ‡π◊ÈÕ∑’Ë¥‘π √–«“ß ‡®â“æπ—°ß“π∑Ë’¥‘π
«—𠇥◊Õπ ªï ®¥∑–‡∫’¬π μ“¡ ≠— ≠“ §ß‡À≈Õ◊ ‡≈¢∑’Ë¥‘π ≈ß≈“¬¡Õ◊ ™ÕË◊
‚©π¥∑¥Ë’ ‘π„À¡à ª√–∑∫— μ√“
«π— ∑.Ë’ ................ ·°â‰¢‡æ¡Ë‘ ‡μ‘¡ ‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
‡¥Õ◊ π...............  ≠— ≠“‡™“à «“ «“
æ.». .................
μ“¡ ≠— ≠“‡™à“∑Ë’¥‘π©∫—∫≈ß«π— ∑’Ë......‡¥◊Õπ..................æ.». .... ∫—¥π’È §àŸ —≠≠“∑Èß—  ÕßΩ“É ¬ › (≈ß™◊ËÕ)........................
‰¥âμ°≈ß‡æ¡‘Ë ‡μ¡‘ ¢âÕ§«“¡„π¢âÕ Ù ·Ààß —≠≠“‡™à“‡¥‘¡ ª√“°Øμ“¡∫π— ∑°÷ ¢Õâ μ°≈ß
·°â‰¢‡æ¡‘Ë ‡μ‘¡ —≠≠“‡™“à ©∫∫— ≈ß«π— ∑.Ë’ .....‡¥Õ◊ π...................æ.». ....

ÛˆÛ

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

∑’Ë «π/‰√à

∑Ë’π“

∑’.Ë .............

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

·≈–°“√ Õ∫ «π ∑‘ ∏‘„π∑¥’Ë π‘ ª√–‡¿∑....‡.≈...°‘ ..‡.™..“à...........................................

μ”·Àπàß∑’Ë¥‘π

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

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

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

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

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

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

‰¥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Ⓞπ∑“ߧ¥Õ’ “≠“‰¥â

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

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

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

Õ¬Ÿà∑’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.....................

Û. ¢â“懮â“...............π..“..¬....°........................... ‡≈¢ª√–®”μ—«ª√–™“™π ºâ.Ÿ ..„..À..‡â.™..“à............................

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

‚ ¥ À¡“â ¬ §àŸ ¡√ ™◊ËÕ....................................................... —≠™“μ.‘ ......................

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

Ù. ¢“â 懮“â ¢Õ· ¥ß√“§“∑√—æ¬∑å Ë’¢Õ∑”π‘μ°‘ √√¡πȇ’ ªπì ‡ßπ‘ ........................ı....,.............................∫“∑.........›........... μ“ߧå

ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à (Àâ“À¡πË◊ ∫“∑∂«â π)

(Ò) ¢“â 懮Ⓣ¡à‰¥â√—∫‚Õπ·∑πÀ√◊Õ‡æÕ◊Ë ª√–‚¬™πå·°à∫§ÿ §≈μ“à ߥ⓫

(Ú) √“§“∑√æ— ¬∑å ·Ë’  ¥ß‰«â„π Ù. ‡ªπì √“§“∑·Ë’ ∑®â √ß‘
(Û) .‡.≈..°‘..‡..™..à“..μ..“..¡.. ...≠— ...≠...“..‡.™..à“..∑..’Ë¥...π‘ ....©..∫..∫—...≈..ß..«..—π..∑...’Ë .........‡.¥...◊Õ..π.......................æ...».......................................................................

(Ù) .....................................................................................................................................................................

(ı) .....................................................................................................................................................................

«π— ∑.’Ë ...........‡¥Õ◊ π..............................æ.»..................
≈ß™◊ÕË .....................π...“.¬....¢.........................ºâŸ¢Õ ‡™à“
≈ß™ËÕ◊ .....................π...“.¬....°..........................ºâŸ¢Õ „À‡â ™“à

≈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..........5..1..3.6....I.V....7..2..2..8..›..1..........‡≈¢∑¥Ë’ ‘π.................Ò..............................Àπâ“ ”√«®...........Ú..............................

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

®”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™◊ÕË .......................................................

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

‡®â“æπ—°ß“π∑Ë’¥‘π

ÛˆÙ

μ«— Õ¬“à ßÀ¡“¬‡≈¢ Ú

(∑.¥. ˘)

§”¢Õ.....®..¥..∑..–..‡.∫...’¬..π..‡.≈..‘°..‡.™..à“.................

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

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

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

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

..............π..“..¬....°........º..âŸ.„.À..â‡..™..à“............................................................

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

Õ¬Ÿà∑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 ......................

¢Õ¬◊Ëπ§”¢ÕμÕà ‡®“â æπ—°ß“π∑’¥Ë π‘ ®—ßÀ«¥— ....................................................¥â«¬§«“¡ μ— ¬®å √‘ß«à“ :-
¢âÕ Ò. ¥â«¬...¢...“â .æ...‡.®..â“....π..“..¬...¢......º..Ÿ‡â.™...à“...°..—∫....π..“..¬....°.....º...Ÿâ„.À..‡â..™..à“...‰.¥...â∑..”.. ..≠—...≠....“..‡.™..à“..∑..Ë’¥...‘π..·..ª...≈..ß..‡.§...√..Õ◊Ë ..ß..À..¡...“.¬...¢..â“..ß..∫..π..π...μ’È ..“..¡.. ...—≠...≠...“...

.‡.™..“à..∑..Ë’¥...π‘ ...©...∫..—∫..≈...ß..«..—π..∑..’.Ë..........‡.¥..Õ◊...π........................................æ.....»..............¡..°’..”..À..π...¥..............................ª..ï..π..—∫...·..μ..à«..π—..∑...’Ë..........‡.¥...◊Õ..π.........................................æ....»..............∫..¥—...π..È’..¢..“â ..æ..‡.®..“â..∑...Èß— .. ..Õ..ß..Ω...“É .¬..
.‰.¥..μâ...°..≈..ß..‡.≈...°‘ .. ..—≠....≠...“..‡.™..à“..μ..àÕ...°..π— ....π..∫— ..·...μ..à«..π— ..∑...’.Ë .........‡.¥...Õ◊ ..π.........................................æ....»..............‡.ª..πì...μ..âπ...‰.ª..................................................................................

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

.....................................................................................................................................................................................................
¢Õâ Ú. ©–ππÈ— ¢Õ„À‡â ®“â æπ°— ß“π∑¥Ë’ π‘ ....®...¥..∑..–..‡..∫..¬’..π...‡.≈..‘°...‡.™..“à..‰.«..â„..π..‚.©...π..¥..∑...Ë’¥..π‘..·...ª..≈..ß..π...’μÈ ..Õà..‰..ª..¥...«â ..¬...¢..â“..æ...‡.®..â“..¬..Õ...¡..‡. ...’¬..................

.§..à“..∏..√..√..¡..‡.π...¬’ ..¡..„..À..μâ..“..¡...√..–..‡.∫..’¬...∫...........................................................................................................................................................

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

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

μ—«Õ¬à“ßÀ¡“¬‡≈¢ Ú

 “√∫—≠®¥∑–‡∫’¬π

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

«π— ∑.’Ë ................ ‡™à“ 𓬠°. Ò › › › › › › (≈ß™ÕË◊ ) 𓬠 .

‡¥Õ◊ π............... (¡’°”Àπ¥............ª)ï

æ.». .................

«—π∑Ë.’ ................ ‡≈°‘ ‡™à“ 𓬠¢. 𓬠°. Ò › › › › › › (≈ß™◊ËÕ).........................
‡¥◊Õπ............... ºâ‡Ÿ ™à“
æ.». .................

Ûˆı

Ûˆˆ

μ«— Õ¬“à ßÀ¡“¬‡≈¢ ÚÒ (∑.¥. Ò)

∑∫Ë’ “â π

∑’Ë «π/‰√à

∑Ë’π“

∑’.Ë .............

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

„π‡¢μ

·≈–°“√ Õ∫ «π ∑‘ ∏‘„π∑¥Ë’ ‘π ª√–‡¿∑...‡.≈..°‘...‡.™..“à..∫..“..ß.. ..«à..π................................

μ”·Àπàß∑’Ë¥‘π

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

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

𓬠¢. ·≈– 𓬠°. μ°≈߬‘π¬Õ¡‡≈‘°‡™à“∫“ß à«π μ“¡∫—π∑÷°¢âÕμ°≈߇≈‘°‡™à“∫“ß à«π©∫—∫≈ß«—π∑’Ë...........‡ ◊¥Õπ..................æ.». ....Àπ“â  ”√«®..................................................................................®—ßÀ«¥— ........................................................................................
 ”À√—∫°“√‡™à“ ’Ë∑¥‘π à «π∑Ë’‡À≈◊Õ —¬ß§ß‡ªìπ‰ªμ“¡ —≠≠“‡™à“ Ë’∑ ‘¥π©∫—∫≈ß«—π∑Ë’...........‡ ◊¥Õπ..................æ.». ....
‚©π¥∑Ë¥’ ‘π
‡ ⮓æπ—°ß“π ’Ë∑¥‘π ‡≈¢∑.Ë’ ....................Ò..Ú...Û..................‡≈à¡............Ò..Û..........................Àπ“â ............Û........................

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

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

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

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

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

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

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

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

Û. ¢â“懮â“...............π..“..¬....°........................... ‡≈¢ª√–®”μ—«ª√–™“™π ºâ.Ÿ ..„..À..‡â.™..“à............................

................................................
Õ“¬.ÿ ...........Û.ı.....................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¡Ÿ∑à 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........................ı....,.............................∫“∑.........›........... μ“ߧå

ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à (À“â À¡Ëπ◊ ∫“∑∂â«π)

(Ò) ¢“â 懮“â ‰¡à‰¥√â ∫— ‚Õπ·∑πÀ√Õ◊ ‡æÕ◊Ë ª√–‚¬™πå·°à∫§ÿ §≈μ“à ߥ“â «

(Ú) √“§“∑√—æ¬å∑’·Ë  ¥ß‰«â„π Ù. ‡ªπì √“§“∑Ë·’ ∑â®√‘ß
(Û) .‡.≈..°‘..‡..™..à“..μ..“..¡.. ...—≠...≠...“..‡.™..“à..©..∫...∫— ..≈...ß..«..π— ..∑...Ë’.........‡.¥...Õ◊ ..π........................æ....»...........‡.æ..’¬...ß..∫..“..ß.. ..«à..π....‡.©...æ..“..–..μ..Õ...π..À..¡...“..¬.. ..’..........................

.μ..“..¡..√..Ÿª...·..º..π..∑...’Ëμ..àÕ..∑...â“..¬..π..’È...................................................................................................................................
(Ù) .®..”.π...«..π..‡.π...ÕÈ◊ ..∑..∑Ë’...’ˇ.≈..°‘...‡.™..à“..∫..“..ß.. ..«à..π......................................................................................................................................................

«π— ∑.’Ë ...........‡¥Õ◊ π..............................æ.»..................
≈ß™◊ÕË .....................π...“.¬....¢.........................ºŸâ¢Õ ‡™“à
≈ß™ÕË◊ .....................π...“.¬....°..........................ºâŸ¢Õ „À‡â ™“à

≈ß™Õ◊Ë ......................................................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..........5..1..3.6....I.V....7..2..2..8..›..1..........‡≈¢∑’¥Ë ‘π.................Ò..............................Àπ“â  ”√«®...........Ú..............................

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

®”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¡“¬‡≈¢ ÚÒ Ûˆ˜

(∑.¥. ˘)

§”¢Õ....®..¥..∑..–..‡.∫..’¬..π..‡..≈..°‘ ..‡.™..à“..∫..“..ß. ..à«..π.......

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

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

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

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

..............π..“..¬....°........º..Ÿâ.„.À..â‡..™..à“............................................................

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

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

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

¢Õ¬◊Ëπ§”¢ÕμÕà ‡®â“æπ°— ß“π∑’Ë¥‘π®—ßÀ«¥— ....................................................¥â«¬§«“¡ —μ¬å®√‘ß«“à :-
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.‡.™..à“..∑..¥Ë’...π‘ ...©...∫..—∫..≈...ß..«..—π..∑..Ë.’..........‡.¥..◊Õ...π........................................æ.....»..............¡..°’..”..À..π...¥..............................ª..ï..π..∫—...·..μ..à«..π—..∑....’Ë .........‡.¥...◊Õ..π.........................................æ....»..............∫..—¥...π..È’..¢..â“..æ..‡.®..â“..∑...ßÈ— .. ..Õ..ß..Ω...“É .¬..
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. ..”..À..√..—∫..°...“.√..‡..™..“à ..∑..¥Ë’..π‘... ..à«..π..∑...‡’Ë .À..≈...Õ◊ ...®..”..π...«..π..‡.π..◊ÈÕ...∑..’Ë....................................................¬...ß— ..§..ß..‡.ª...ìπ..‰.ª...μ..“..¡.. ...≠— ...≠...“..‡.™..“à..‡..¥..‘¡...............................................................

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¢Õâ Ú. ©–ππÈ— ¢Õ„À‡â ®“â æπ°— ß“π∑¥’Ë π‘ .....®..¥..∑..–..‡..∫..¬’..π...‡.≈..°‘...‡.™..à“..∫..“..ß.. ..à«..π...‰.«..â„..π..‚.©...π..¥..∑...Ë¥’ ..π‘..·...ª..≈..ß..π...μÈ’ ..àÕ..‰..ª..¥...«â ..¬...¢..“â..æ...‡.®..â“..¬..Õ...¡..‡. ...¬’ .....

.§..“à ..∏..√..√..¡..‡.π...¬’ ..¡..„..À..âμ..“..¡...√..–..‡.∫..’¬...∫...........................................................................................................................................................

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

▼Ûˆ¯

μ«— Õ¬“à ßÀ¡“¬‡≈¢ ÚÒ

·ºπ∑∑Ë’ ⓬§”¢Õ®¥∑–‡∫¬’ π‡≈°‘ ‡™à“∫“ß à«π
©∫—∫≈ß«—π∑.Ë’ ........‡¥◊Õπ............................æ.». ....

N ‚©π¥‡≈¢∑.’Ë .................‡≈¢∑¥Ë’ π‘ ....................Àπâ“ ”√«®...............

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

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‡¢μ∑¥Ë’ π‘ ‚©‹π¥‡≈¢∑.Ë’ ............∑Ë’‰¥®â ¥∑–‡∫¬’ π‡™à“‰«â ‡π◊ÈÕ∑Ë’ Ò ‰√à
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≈ß™ÕË◊ .......................π..“..¬....¢.......................ºâŸ‡™à“
≈ß™Õ◊Ë .......................π..“..¬....°........................ºâŸ„À⇙à“
≈ß™Õ◊Ë ......................................................欓π
≈ß™Õ◊Ë ......................................................欓π
≈ß™ÕË◊ ......................................................‡®“â æπ°— ß“π∑’Ë¥π‘

μ—«Õ¬à“ßÀ¡“¬‡≈¢ ÚÒ Ûˆ˘

(∑.¥. Òˆ)

∫—π∑÷°¢âÕμ°≈߇≈°‘ ‡™“à ∫“ß «à π

∑Ë’¥‘π
√–«“ß.............5..1..3.6....I.V....7..2..2..8..›..1..........................................μ”∫≈........................................................................
‡≈¢∑’Ë¥‘π..................Ú..Û...........Àπ“â  ”√«®..........Ù..Ù................Õ”‡¿Õ.......................................................................
‚©π¥À¡“¬‡≈¢∑Ë’...............ı..Û...˘..Ò.........................................®—ßÀ«¥— .......................................................................

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

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

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

.....................π..“..¬....°.......º..Ÿâ„.À...‡â .™..à“......................................................

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

Õ¬Ÿà∑’∫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//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’ :›
......................¢..â“..æ...‡.®...“â .π...“..¬....¢....º...‡âŸ .™...à“...°..—∫....π...“..¬....°.....º..Ÿâ„..À..‡â.™...“à ...‰..¥..∑â...”.. ..—≠...≠....“..‡.™..“à..‰..«..μâ ..àÕ...°..π—...μ..“..¡... ..—≠....≠...“..‡.™...à“.∑...Ë’¥...‘π...©...∫..—∫...≈..ß...«..π— ..∑...Ë’ .........‡.¥...Õ◊ ..π..................
æ.....»..............¡...’°..”..À...π..¥..............................................ª..ï..∫..—¥...π..’È..¢..“â..æ...‡.®..“â..∑...È—ß.. ..Õ...ß..Ω..É“..¬...‰.¥...μâ ..°...≈..ß..‡.≈...°‘.. ...—≠...≠....“..‡.™..à“..∑...’Ë¥..‘π...∫..“..ß.. ...«à ..π....®..”..π..«..π...‡.π...È◊Õ..∑...’.Ë .................................................................μ..Õà...°..—π...
π...—∫...·..μ..à«..—π...∑...Ë’..............‡.¥...◊Õ..π........................................æ....»...............‡.©...æ..“..–...μ..Õ...π..À...¡..“..¬.. ...’·..¥...ß..μ..“..¡...·..º...π..∑...’∑Ë ..â“..¬..§...”..¢..Õ....©...∫..—∫...«..—π..∑...Ë.’ .............‡.¥...◊Õ..π........................................æ.....».............. ...”..À..√..∫—........
°...“..√..‡.™...“à ..∑..Ë¥’...π‘ .. ..«à...π..∑..’‡Ë..À..≈...◊Õ....®..”..π..«..π...‡.π...◊ÈÕ..∑...Ë.’ .............................................¬...ß— ..§..ß..‡..ª..ìπ...‰.ª...μ..“..¡... ..≠—....≠...“..‡.¥...‘¡.......................................................................................
......................∫...π— ..∑...÷°..¢..âÕ...μ..°...≈..ß..π...∑È’ ..”..¢..÷Èπ...À..π...ß÷Ë ..©..∫...∫—....‡.°...∫Á ..‰..«..â .≥..... ...”..π..—°...ß..“..π..∑...’¥Ë ..π‘....¢..“â..æ...‡.®...â“..∑..—ßÈ.. ...Õ..ß..Ω...“É ..¬..‰..¥..μâ...√..«..®..∫..—π...∑..°÷...¢..Õâ...μ..°..≈...ß....·..≈..–...‡.¢..“â..„..®..........
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............................................................................................≈..ß...™..◊ËÕ...........................................................π......“....¬.........¢......................................................º..Ÿâ‡..™..à“............................................
............................................................................................≈..ß...™..Ë◊Õ...........................................................π......“....¬.........°......................................................º..Ÿâ.„.À...‡â .™..“à........................................
............................................................................................≈..ß...™..◊ËÕ....................................................................................................................................æ...¬..“..π...........................................
............................................................................................≈..ß...™..◊ËÕ.....................................................................................................................................æ...¬..“..π...........................................
.............................∫...—π..∑...÷°..¢..âÕ...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...πì .. ...”..§..—≠..........................................................

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μ«— Õ¬“à ßÀ¡“¬‡≈¢ ÚÒ Û˜

 “√∫—≠®¥∑–‡∫¬’ π

®¥∑–‡∫’¬π ª√–‡¿∑°“√ ºâŸ„À â ≠— ≠“ ºŸâ√—∫ —≠≠“ ‡π◊ÈÕ∑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◊ ™Õ◊Ë
𓬠¢. ‚©π¥∑Ë¥’ ‘π„À¡à ª√–∑∫— μ√“
ºâ‡Ÿ ™à“ ‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
«“ «“

«—π∑’.Ë ................ ‡™à“ 𓬠°. Ò › › › › › › (≈ß™ÕË◊ ) 𓬠 .

‡¥Õ◊ π............... (¡°’ ”Àπ¥............ªï)

æ.». .................

«—π∑’Ë................. ‡≈‘°‡™“à ∫“ß à«π 𓬠¢. 𓬠°. Ò › › › › › › (≈ß™Õ◊Ë ).........................
‡¥Õ◊ π............... ºâ‡Ÿ ™à“
æ.». ................. 𓬠¢. ·≈– 𓬠°. μ°≈ß¬π‘ ¬Õ¡‡≈‘°‡™“à

∫“ß à«π μ“¡∫π— ∑÷°¢Õâ μ°≈߇≈°‘ ‡™“à ∫“ß «à π

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

 ”À√∫— °“√‡™à“∑¥Ë’ ‘π «à π∑‡’Ë À≈Õ◊ ¬—ߧ߇ªπì ‰ª

μ“¡ ≠— ≠“‡™à“©∫—∫≈ß«π— ∑’.Ë .......‡¥◊Õπ................

æ.». ....

μ—«Õ¬“à ßÀ¡“¬‡≈¢ ÚÚ Û˜Ò

(∑.¥. Ò)
∑∫Ë’ “â π

∑’ Ë «π/‰√à

∑’Ëπ“

∑Ë.’ .............

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

„π‡¢μ

·≈–°“√ Õ∫ «π ∑‘ ∏‘„π∑Ë¥’ π‘ ª√–‡¿∑...‡.≈..‘°...‡.™..“à..™..«à..ß......................................

μ”·Àπàß∑Ë’¥‘π

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

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

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

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

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

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

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

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

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

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

Õ¬Ÿà∑∫’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.....................

Û. ¢â“懮â“...............π..“..¬....¢........................... ‡≈¢ª√–®”μ—«ª√–™“™π ºŸâ...„..À..‡â .™..“à..™..«à..ß......................

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

‚ ¥ À¡“â ¬ §àŸ ¡√ ™ËÕ◊ ....................................................... —≠™“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°‘ √√¡πÈ’‡ªìπ‡ßπ‘ ........................ı....,.............................∫“∑.........›........... μ“ߧå

ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à (À“â À¡Ëπ◊ ∫“∑∂â«π)

(Ò) ¢“â 懮Ⓣ¡à‰¥√â ∫— ‚Õπ·∑πÀ√Õ◊ ‡æ◊ÕË ª√–‚¬™πå·°∫à §ÿ §≈μà“ߥ⓫

(Ú) √“§“∑√æ— ¬å∑Ë·’  ¥ß‰«â„π Ù. ‡ªìπ√“§“∑’Ë·∑â®√‘ß
(Û) .‡.≈..°‘..‡..™..à“..™..«à ..ß..μ..“..¡.. ...—≠...≠...“..‡.™..“à..™..«à..ß..©...∫..∫—...≈..ß..«..—π..∑..Ë.’ ........‡.¥...◊Õ..π.........................æ...»...................................................................

(Ù) .....................................................................................................................................................................

(ı) .....................................................................................................................................................................

«π— ∑.’Ë ...........‡¥Õ◊ π..............................æ.»..................
≈ß™ËÕ◊ .....................π...“..¬...®.........................ºŸâ¢Õ ‡™à“™à«ß
≈ß™Õ◊Ë .....................π...“.¬....¢..........................ºâŸ¢Õ „Àâ‡™à“™«à ß

≈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..............................Àπ“â  ”√«®...........Ú..............................

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

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

≈ß™◊ËÕ.......................................................

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

‡®â“æπ—°ß“π∑Ë’¥‘π

Û˜Ú

μ—«Õ¬à“ßÀ¡“¬‡≈¢ ÚÚ

(∑.¥. ˘)

§”¢Õ....®..¥..∑..–..‡.∫..’¬..π..‡..≈..°‘ ..‡.™..à“..™..«à .ß.............

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

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

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

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

..............π..“..¬....¢........º..âŸ.„.À..‡â..™..“à ..™..à«..ß......................................................

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

Õ¬àŸ∑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 ......................

¢Õ¬Ë◊π§”¢ÕμÕà ‡®“â æπ°— ß“π∑¥’Ë π‘ ®ß— À«¥— ....................................................¥â«¬§«“¡ —μ¬å®√‘ß«“à :-
¢Õâ Ò. ¥«â ¬...¢...“â .æ...‡.®..“â....π..“..¬...®......º..⇟.™..“à..™..à«..ß....°..—∫....π..“..¬....¢.....º..Ÿâ.„.À..â‡..™..à“..™..«à ..ß...‰..¥..â∑..”.. ..≠—....≠...“..‡.™..à“..™..«à..ß..∑..¥Ë’...‘π..·..ª...≈..ß..‡.§...√..Õ◊Ë ..ß..À..¡...“..¬..¢..â“..ß..∫..π...π..È’

.μ..“..¡.. ..≠—....≠...“..‡.™..à“..™..à«..ß..∑..¥’Ë...π‘ ....©..∫..∫—...≈..ß..«..π—..∑...Ë’..........‡.¥...Õ◊ ..π.........................................æ....»..............¡..’°..”..À...π..¥..............................ª...ï .π..—∫...·..μ..«à..π—...∑...Ë’.........‡..¥..Õ◊..π.........................................æ....»............................
∫...¥— ..π...È’ .¢..â“..æ...‡.®..â“..∑..È—ß.. ..Õ...ß..Ω..“É..¬..‰..¥..âμ..°...≈..ß..‡.≈..°‘... ..≠—...≠...“..‡..™..à“..™..à«..ß..μ..Õà..°...π— ...π...—∫..·..μ...«à ..—π..∑...’Ë..........‡.¥..Õ◊...π........................................æ.....»..............‡.ª..ìπ...μ..âπ..‰..ª......................................

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¢Õâ Ú. ©–ππÈ— ¢Õ„À‡â ®“â æπ°— ß“π∑¥’Ë π‘ ....®...¥..∑..–..‡..∫..’¬..π...‡.≈..°‘...‡.™..à“..™..«à..ß..‰.«..â.„.π..‚..©..π..¥...∑..¥’Ë ..π‘...·..ª..≈...ß..π..È’μ..àÕ...‰.ª..¥...«â ..¬....¢..“â ..æ..‡.®..“â..¬..Õ...¡..‡. ...’¬............

§...“à ..∏..√..√..¡..‡.π...’¬..¡..„..À..μâ..“..¡...√..–..‡.∫..¬’...∫...........................................................................................................................................................

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

μ—«Õ¬“à ßÀ¡“¬‡≈¢ ÚÚ

 “√∫—≠®¥∑–‡∫’¬π

®¥∑–‡∫’¬π ª√–‡¿∑°“√ ºŸâ„À â ≠— ≠“ ºŸâ√—∫ —≠≠“ ‡π◊ÈÕ∑’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◊
𓬠®. ‚©π¥∑¥Ë’ π‘ „À¡à ª√–∑∫— μ√“
º‡âŸ ™à“™à«ß ‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
«“ «“

«—π∑.’Ë ................ ‡™à“™«à ß π“¬ ¢. Ò › › › › › › (≈ß™ËÕ◊ ) 𓬠 .

‡¥Õ◊ π............... (¡’°”Àπ¥............ªï) ºâ‡Ÿ ™“à

æ.». .................

«π— ∑Ë.’ ................ ‡≈‘°‡™“à ™«à ß π“¬ ¢. 𓬠°. Ò › › › › › › (≈ß™ËÕ◊ ).........................
‡¥◊Õπ............... º‡âŸ ™à“™«à ß ºŸâ„À⇙“à ™«à ß
æ.». .................

Û˜Û

Û˜Ù

μ—«Õ¬à“ßÀ¡“¬‡≈¢ ÚÛ (∑.¥. Ò)

∑∫Ë’ “â π

∑’ Ë «π/‰√à

∑’Ëπ“

∑Ë.’ .............

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

„π‡¢μ

·≈–°“√ Õ∫ «π ‘∑∏‘„π∑’¥Ë ‘π ª√–‡¿∑...‡.≈..°‘...‡.™..“à..™..«à..ß..∫..“..ß.. ...«à ..π.........................

μ”·Àπàß∑Ë’¥‘π

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

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

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

𓬠®. ·≈– 𓬠¢. μ°≈߬‘π¬Õ¡‡≈‘°‡™à“™à«ß∫“ß à«π μ“¡∫—π∑÷°¢âÕμ°≈ß©∫—∫≈ß«—π∑’Ë...........‡ ◊¥Õπ..................æ.». ....‚©π¥∑Ë¥’ ‘π
 ”À√—∫°“√‡™à“∑Ë’¥‘π à«π∑Ë’‡À≈◊Õ¬—ߧ߇ªìπ‰ªμ“¡ —≠≠“‡™à“™à«ß©∫—∫≈ß«—π∑Ë’...........‡¥◊Õπ..................æ.». .... ‡≈¢∑.Ë’ ....................Ò..Ú...Û..................‡≈¡à ............Ò..Û..........................Àπâ“............Û........................

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

Ò. ¢â“懮⓺¡Ÿâ π’ “¡μÕà ‰ªπ’È ¡§’ «“¡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“â „À∂â Õâ ¬§”‰¡à‡ªπì §«“¡®√‘ß„Àâ„™∂â Õâ ¬§”π’¬È —π¢“â 懮Ⓞπ∑“ߧ¥’Õ“≠“‰¥â

Ú. ¢â“懮â“..............π..“..¬...®............................. ‡≈¢ª√–®”μ—«ª√–™“™π º.⟠..‡.™..“à..™..à«..ß..........................

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

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

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..“..¬....¢........................... ‡≈¢ª√–®”μ—«ª√–™“™π º.Ÿâ ..„..À..‡â.™..à“..™..«à..ß......................

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

‚ ¥ À¡“â ¬ § àŸ ¡√ ™Õ◊Ë ....................................................... ≠— ™“μ.‘ ......................

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

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

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

ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à (Àâ“À¡π◊Ë ∫“∑∂«â π)

(Ò) ¢“â 懮Ⓣ¡à‰¥â√∫— ‚Õπ·∑πÀ√◊Õ‡æË◊Õª√–‚¬™π·å °à∫ÿ§§≈μ“à ߥ“â «

(Ú) √“§“∑√—æ¬∑å ·’Ë  ¥ß‰«â„π Ù. ‡ªìπ√“§“∑’·Ë ∑â®√‘ß
(Û) .‡.≈..‘°..‡..™..à“..™..«à ..ß..μ..“..¡.. ...≠— ...≠...“..‡.™..à“..™..à«..ß..©...∫..—∫...≈..ß..«..—π..∑..’Ë.........‡.¥...◊Õ..π.........................æ...»..........‡.æ...¬’ ..ß..∫..“..ß.. ...à«..π...‡..©..æ..“..–..μ...Õ..π..À...¡..“..¬.. ..’·...¥..ß..

.μ..“..¡..√..Ÿª...·..º..π..∑...’Ëμ..Õà..∑...“â ..¬..π..’È...................................................................................................................................
(Ù) .®..”.π...«..π..‡.π...ÈÕ◊ ..∑..’Ë∑...‡Ë’ .≈..°‘...‡.™..à“..™..à«..ß..∫..“..ß.. ...à«.π......................................................................................................................................................

«π— ∑.’Ë ...........‡¥Õ◊ π..............................æ.»..................
≈ß™◊ËÕ.....................π...“..¬...®.........................ºŸâ¢Õ ‡™“à ™«à ß
≈ß™Ë◊Õ.....................π...“.¬....¢..........................ºâŸ¢Õ „À⇙“à ™à«ß

≈ß™Ë◊Õ......................................................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“ ”√«®...........Ú..............................

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

®”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’.................................‡¥Õ◊ π............................................æ.»......................

≈ß™◊ÕË .......................................................

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

‡®â“æπ—°ß“π∑’Ë¥‘π

μ—«Õ¬“à ßÀ¡“¬‡≈¢ ÚÛ Û˜ı

(∑.¥. ˘)

§”¢Õ..®..¥...∑..–..‡.∫...’¬..π..‡..≈..‘°..‡.™...“à .™...à«..ß..∫..“..ß.. ..à«..π....

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

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

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

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

..............π..“..¬....¢........º..Ÿâ.„.À..‡â..™..“à ..™..«à ..ß......................................................

Õ“¬.ÿ .Û..ı...,..ı......ªï ‡™È◊Õ™“μ.‘ ............................ —≠™“μ‘......‰.∑..¬...,...‰..∑..¬..........∫‘¥“/¡“√¥“™◊ËÕ.....................................................................

Õ¬àŸ∑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 ......................

¢Õ¬Ëπ◊ §”¢ÕμàÕ‡®â“æπ°— ß“π∑’¥Ë π‘ ®—ßÀ«¥— ....................................................¥«â ¬§«“¡ μ— ¬å®√ß‘ «“à :-
¢âÕ Ò. ¥«â ¬....¢..â“..æ..‡.®..â“....π..“..¬...®......º..⇟.™...“à .™...à«.ß....°..—∫....π..“..¬....¢.....º...⟄.À..â‡..™..à“..™..à«..ß...‰..¥..∑â..”.. ..—≠....≠...“..‡.™..à“..™..«à..ß..∑...¥Ë’ ..π‘ ..·..ª...≈..ß..‡.§...√..ËÕ◊ ..ß..À...¡..“..¬..¢..â“..ß..∫..π...π..È’

.μ..“..¡.. ..—≠....≠...“..‡.™..à“..™..«à..ß....©..∫..∫—...≈..ß..«..—π..∑....Ë’ .........‡.¥...◊Õ..π.........................................æ....»..............¡..°’..”..À...π..¥..............................ª...ï .π..∫—...·..μ..«à..π—...∑...’Ë.........‡..¥..Õ◊..π.........................................æ....»..............∫...¥— ..π..È’..¢..â“..æ..‡..®..“â ..
.∑..ß—È .. ..Õ...ß..Ω..É“..¬..‰.¥...âμ..°..≈...ß..¬..π‘ ..¬...Õ..¡..„..À..ºâ ..‡âŸ.™...“à .‡..≈..°‘..‡..™..à“..™..à«..ß..∫..“..ß.. ..à«..π...„.π..∑...Ë’¥..π‘..·...ª..≈..ß..¥...ß— ..°..≈..à“..«...®...”.π...«..π..‡.π...◊ÈÕ..∑..Ë.’.........................................................‡.©..æ...“..–..μ..Õ..π...À..¡..“..¬... ..’·..¥..ß....
μ...“..¡..·..º...π..∑..Ë∑’...“â .¬...§..”..¢..Õ..π...È’ . ..”..À...√..—∫..°..“..√..‡.™...“à .™...«à ..ß..∑..Ë¥’ ..‘π... ..à«..π..∑...ˇ’ .À..≈..◊Õ....®..”..π..«..π...‡.π..ÈÕ◊...∑...Ë’...................................................¬...ß— ..§..ß..‡.ª...πì ..‰.ª...μ..“..¡.. ...—≠...≠...“..‡.™..à“..‡.¥...‘¡......................

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¢âÕ Ú. ©–ππÈ— ¢Õ„À‡â ®“â æπ°— ß“π∑¥’Ë π‘ .....®..¥..∑..–..‡..∫..’¬..π...‡.≈..°‘...‡.™..“à..™..«à..ß..∫..“..ß.. ...à«..π..‰.«..â„..π..‚.©...π..¥..∑...¥’Ë ..π‘...·..ª..≈...ß..π..Èμ’ ..àÕ...‰.ª..¥...â«..¬...¢...â“.æ...‡.®..â“..¬..Õ...¡.....

.‡. ..¬’..§...“à ..∏..√..√..¡..‡.π...’¬..¡..„..À..μâ..“..¡...√..–..‡.∫..’¬...∫.....................................................................................................................................................

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........................π..“..¬....®......................... ºâŸ¢Õ
........................π..“..¬....¢......................... ºâŸ¢Õ

........................................................ 欓π
........................................................ 欓π

▼Û˜ˆ

μ—«Õ¬à“ßÀ¡“¬‡≈¢ ÚÛ

·ºπ∑Ë∑’ “â ¬§”¢Õ‡√Ë◊Õ߇≈°‘ ‡™“à ™«à ß∫“ß «à π
©∫∫— ≈ß«π— ∑’Ë.........‡¥◊Õπ............................æ.». ....

N ‚©π¥‡≈¢∑’.Ë .................‡≈¢∑’Ë¥π‘ ....................Àπ“â  ”√«®...............

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

ı ‰√à111111111111111111122222222222222222223333333333333333333444444444444444444455555555555555555556666666666666666666777777777777777777788888888888888888889999999999999999999000000000000000000011111111111111111112222222222222222222333333333333333333344444444444444444445555555555555555555

‡¢μ∑Ë’¥π‘ ‚©π‹ ¥‡≈¢∑Ë.’ ...............∑Ë®’ ¥∑–‡∫’¬π‡™à“™«à ß ‡πÈÕ◊ ∑’Ë Ò ‰√à
111222333444555666777888999000111222 ‡¢μ ·’ ¥ß ‡ªìπ‡¢μ∑®’Ë ¥∑–‡∫¬’ π‡≈‘°‡™“à ™«à ß∫“ß «à π ‡πÕ◊È ∑Ë’ª√–¡“≥ ı ‰√à

≈ß™Õ◊Ë .......................π..“..¬....®.......................º‡âŸ ™“à ™«à ß
≈ß™ÕË◊ .......................π..“..¬....¢........................ºâŸ„À‡â ™“à ™«à ß
≈ß™ÕË◊ ......................................................欓π
≈ß™ÕË◊ ......................................................欓π
≈ß™ÕË◊ ......................................................‡®“â æπ—°ß“π∑¥Ë’ ‘π

μ—«Õ¬“à ßÀ¡“¬‡≈¢ ÚÛ Û˜˜

(∑.¥. Òˆ)

∫π— ∑°÷ ¢Õâ μ°≈߇≈‘°‡™à“™«à ß∫“ß «à π

∑’Ë¥‘π
√–«“ß.............5..1..3.6....I.V....7..2..2..8..›..1..........................................μ”∫≈........................................................................
‡≈¢∑¥Ë’ ‘π..................Ú..Û...........Àπ“â  ”√«®..........Ù..Ù................Õ”‡¿Õ.......................................................................
‚©π¥À¡“¬‡≈¢∑Ë’...............ı..Û...˘..Ò.........................................®—ßÀ«—¥.......................................................................

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

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

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

.....................π..“..¬....¢.......º..Ÿâ„.À...‡â .™..à“..™..à«..ß................................................

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

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

μ”∫≈/·¢«ß...............................Õ”‡¿Õ/‡¢μ...............................®ß— À«—¥................................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’ :›
......................¢..“â..æ...‡.®...â“.π...“..¬....®....º...Ÿ‡â .™..“à..™...«à ..ß...°...∫— ....π..“..¬....¢.....º..Ÿâ.„.À..‡â..™..à“..™..«à..ß....‰..¥..∑â...”. ...≠—...≠....“..‡.™..“à..™...«à ..ß..‰.«..âμ...Õà ..°...—π..μ...“..¡.. ...≠— ...≠...“..‡..™..à“..™..à«..ß..∑...’¥Ë...π‘ ...©...∫..∫—...≈..ß...«..—π..∑...Ë’ ..
.‡.¥..Õ◊...π...............................æ....»...............¡..°’...”..À..π...¥....................ª...ï .∫...¥— ..π...’È .¢..“â..æ...‡.®...â“..∑..—Èß.. ...Õ..ß..Ω...É“..¬..‰.¥...âμ...°..≈..ß...‡.≈..°‘... ..≠—....≠...“..‡.™...“à ..™..«à ..ß..∑...¥Ë’ ..‘π...∫..“..ß.. ...«à ..π....®..”..π..«..π...‡.π...◊ÈÕ..∑...Ë.’ ...........................μ...Õà ..°...—π..
π...—∫...·..μ..«à..π—...∑..’.Ë...................‡.¥...Õ◊..π............................................æ....»...............‡.©...æ..“..–...μ..Õ...π..À..¡...“..¬.. ...’·..¥...ß..μ..“..¡...·..º...π..∑...∑Ë’ ..“â..¬..§...”..¢..Õ....©...∫..—∫...«..π— ..∑....’Ë ..................‡..¥..◊Õ...π......................................æ....»............... ..”..À...√..∫— ..
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......................∫...—π..∑...°÷ ..¢..Õâ...μ..°...≈..ß..π...’ȉ.¥...â∑..”..‰..«..âÀ..π...÷Ëß..©..∫...—∫....‡.°...∫Á ..‰..«..â .≥..... ...”..π..—°...ß..“..π..∑...Ë¥’ ..‘π....¢..â“..æ...‡.®...â“..∑..Èß—.. ...Õ..ß..Ω...“É ..¬..‰.¥...âμ...√..«..®..∫..π—...∑..°÷...¢..âÕ...μ..°..≈...ß....·..≈..–...‡.¢..â“..„..®.......
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............................................................................................≈..ß...™..◊ËÕ...........................................................π......“....¬.........®......................................................º..Ÿâ‡..™..à“..™..à«..ß......................................
............................................................................................≈..ß...™..◊ËÕ...........................................................π......“....¬.........¢......................................................º..âŸ.„.À...‡â .™..“à..™..«à..ß..................................
............................................................................................≈..ß...™..◊ËÕ....................................................................................................................................æ...¬..“..π...........................................
............................................................................................≈..ß...™..Ë◊Õ.....................................................................................................................................æ...¬..“..π...........................................
.............................∫...—π..∑...°÷ ..¢..âÕ...μ..°...≈..ß..π...’ȉ..¥..∑â...”..μ..Õà...À..π...“â ......................................................................................................................................
............................................................................................≈..ß...™..Ë◊Õ.....................................................................................................................................‡.®..“â..æ...π...°— ..ß..“..π..∑...¥’Ë..π‘..........................
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μ«— Õ¬“à ßÀ¡“¬‡≈¢ ÚÛ Û˜¯

 “√∫≠— ®¥∑–‡∫¬’ π

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

«π— ∑Ë’................. ‡™à“™«à ß π“¬ ¢. Ò › › › › › › (≈ß™ÕË◊ ) 𓬠 .

‡¥◊Õπ............... (¡°’ ”Àπ¥............ªï) º‡Ÿâ ™à“

æ.». .................

«—π∑.’Ë ................ ‡≈°‘ ‡™“à ™à«ß∫“ß «à π 𓬠®. 𓬠¢. Ò › › › › › › (≈ß™◊ÕË ).........................

‡¥◊Õπ............... ºâŸ‡™à“™à«ß ºŸâ„Àâ‡™à“™à«ß 𓬠®. ·≈– 𓬠¢. μ°≈߬‘π¬Õ¡‡≈‘°
æ.». ................. ‡™“à ™«à ß∫“ß à«π μ“¡∫π— ∑°÷ ¢âÕμ°≈ß©∫—∫
≈ß«π— ∑.’Ë .......‡¥◊Õπ.....................æ.». .... ”À√∫—
°“√‡™à“∑¥Ë’ ‘π à«π∑ˇ’ À≈◊Õ¬—ߧ߇ªìπ‰ªμ“¡
 ≠— ≠“‡™“à ™«à ß©∫—∫≈ß«π— ∑Ë.’ ......‡¥Õ◊ π................
æ.». ....

Û˜˘

μ—«Õ¬à“ßÀ¡“¬‡≈¢ ÚÙ (∑.¥. Ò)
∑∫Ë’ “â π

∑Ë’ «π/‰√à

∑’Ëπ“

∑.’Ë .............

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

„π‡¢μ

·≈–°“√ Õ∫ «π ∑‘ ∏‘„π∑¥’Ë π‘ ª√–‡¿∑...ª..≈..Õ...¥..°..“..√..‡..™..“à ..................................

μ”·Àπàß∑Ë’¥‘π

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

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

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

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

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

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

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

∑Ë’¥‘π·ª≈ßπÈ’æâπ®“°°“√‡™à“ μ“¡ —≠≠“‡™à“∑’Ë ‘¥π√«¡ Õß‚©π¥ ©∫—∫≈ß«—π∑Ë’...........‡¥◊Õπ..................æ.». .... Ú. ¢â“懮“â ..............π..“..¬...¢............................. ‡≈¢ª√–®”μ—«ª√–™“™π ºŸ.â ..‡.™..à“................................
μ“¡∫—π∑÷°¢âÕμ°≈ߪ≈Õ¥°“√‡™à“©∫—∫≈ß«—π∑’Ë...........‡ ◊¥Õπ..................æ.». ....
.................................................
‡ ⮓æπ—°ß“π ’Ë∑¥‘π Õ“¬.ÿ ............ı.....................ªï  ≠— ™“μ‘.................‰..∑..¬....................∫‘¥“/¡“√¥“™ÕË◊ .............................................................................

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

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

Û. ¢“â 懮“â ...............π..“..¬....°........................... ‡≈¢ª√–®”μ—«ª√–™“™π ºâŸ...„..À..‡â .™..“à............................

................................................
Õ“¬.ÿ ............Ûı.....................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“â ¢Õ· ¥ß√“§“∑√—æ¬∑å Ë¢’ Õ∑”π‘μ‘°√√¡πÈ’‡ªìπ‡ßπ‘ ........................ı....,.............................∫“∑.........›........... μ“ߧå

ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à (À“â À¡◊Ëπ∫“∑∂«â π)

(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) .∑..Ë¥’ ..‘π...·..ª..≈...ß..π..’ȉ..¥..‡â.™..à“..‰..«..â√..«.¡...°..∫—..‚..©..π..¥...∑..Ë¥’...π‘ ..‡.≈..¢...∑..Ë’..........................μ..“..¡... ..≠— ...≠...“..‡.™...“à .∑...¥’Ë ..‘π..√..«..¡... ..Õ..ß..‚..©..π..¥....©..∫...—∫..≈...ß..«..—π..∑...’Ë ...........

.‡.¥..Õ◊...π.................................æ....»..............‰..¥..âæ...âπ..®..“..°..‡.™...à“...μ..“..¡..∫...—π..∑..÷°...¢..âÕ..μ...°..≈..ß..ª...≈..Õ..¥...°..“..√..‡.™..à“..©..∫...∫— ..≈..ß..«..π—...∑...Ë’...............‡.¥..◊Õ...π.................................æ.....»..............

(Ù) .....................................................................................................................................................................

«π— ∑.Ë’ ...........‡¥Õ◊ π..............................æ.»..................
≈ß™Ë◊Õ.....................π...“..¬...¢.........................ºâŸ¢Õ ‡™à“
≈ß™ËÕ◊ .....................π...“.¬....°..........................ºâŸ¢Õ „À‡â ™“à

≈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..........5..1.3..6....I.V....7..2..2..8..›.1...........‡≈¢∑Ë¥’ π‘ .................Ò..............................Àπ“â  ”√«®...........Ú..............................

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

®”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™ËÕ◊ .......................................................

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

‡®â“æπ—°ß“π∑’Ë¥‘π

Û¯

μ—«Õ¬“à ßÀ¡“¬‡≈¢ ÚÙ

(∑.¥. Òˆ)

∫π— ∑÷°¢Õâ μ°≈ߪ≈Õ¥°“√‡™à“

∑Ë’¥‘π
√–«“ß.............5..1.3..6....I.V....7..2..2..8..›.1...........................................μ”∫≈........................................................................
‡≈¢∑’¥Ë ‘π.................Ú...Û...........Àπâ“ ”√«®..........Ù..Ù................Õ”‡¿Õ.......................................................................
‚©π¥À¡“¬‡≈¢∑Ë’...............ı..Û...˘..Ò.........................................®—ßÀ«¥— .......................................................................

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

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

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

.....................π..“..¬....°........º..Ÿâ.„.À..â‡..™..“à ....................................................

Õ“¬.ÿ ..ı.....,..Û.........ªï ‡™Õ◊È ™“μ.‘ .............................. —≠™“μ.‘ .......‰..∑..¬..,...‰.∑..¬...........∫¥‘ “/¡“√¥“™ÕË◊ ............................................................

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/Õà//.....‰..¥..â∑...”.∫...—π..∑..°÷...¢..âÕ..μ...°..≈..ß..μ..Õà...‡.®..â“..æ..π...—°..ß..“..π..∑...’¥Ë ..‘π.....................................................................................

¥//«â//¬//§//«/“/¡// //μ—//¬//®å /√//ß‘ / ¥—ßμÕà ‰ªπ’È :›
......................∑...’Ë¥..‘π...·..ª..≈...ß..‡.§...√..ÕË◊...ß..À..¡...“..¬..¢..“â..ß..∫...π..π...È’.¢...â“..æ..‡..®..“â ..π..“..¬....¢.....‰.¥...â‡.™..“à..∑...Ë’¥..‘π...‰.«..â°...—∫..π...“..¬....°....‚..¥..¬...‰.¥...â‡.™..à“..∑...Ë¥’ ..‘π...√..«..¡.. ...Õ..ß..·...ª..≈...ß..‰.«..â°...∫— ..‚..©..π...¥..∑...Ë’¥..‘π..
‡..≈..¢...∑..Ë.’.............................μ...“..¡.. ...—≠...≠....“..‡.™..“à..∑...¥Ë’ ..π‘...√..«..¡.. ...Õ..ß..‚..©..π...¥....©..∫...—∫..≈...ß..«..—π...∑..Ë’................‡.¥...Õ◊..π...............................æ.....»..............∫...—¥..π...’È.¢...“â ..æ..‡..®..â“..∑..Èß—.. ...Õ..ß...Ω..“É..¬..‰..¥..μâ...°..≈...ß..°..π—...„.À...∑â ..’Ë¥...‘π...
·...ª..≈...ß..‡.§...√..Õ◊Ë..ß...À..¡...“..¬..¢..“â..ß..∫...π..π...È’æ..âπ...®..“..°..°...“..√..‡.™...“à ... ..«à...π..‚.©...π..¥...∑..¥Ë’...‘π..‡..≈..¢..∑....’Ë...............................§...ß..¡..°’...“..√..‡.™..à“..Õ...¬..Ÿμà...“..¡..‡..¥..¡‘...........................................................
......................∫...π— ..∑...°÷ ..¢..Õâ...μ..°...≈..ß..π...’ȉ.¥...â∑..”..‰..«..Àâ..π...Ëß÷ ..©..∫...∫—....‡.°...Á∫..‰..«..â.≥..... ...”..π..—°...ß..“..π..∑...Ë’¥..π‘....¢..â“..æ...‡.®...â“..∑..È—ß.. ...Õ..ß..Ω...“É ..¬..‰..¥..âμ...√..«..®..∫..—π...∑..°÷...¢..âÕ...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...™..Ë◊Õ...........................................................π......“....¬.........¢......................................................º..Ÿâ‡..™..à“............................................
............................................................................................≈..ß...™..Ë◊Õ...........................................................π......“....¬.........°......................................................º..Ÿâ.„.À...‡â .™..“à........................................
............................................................................................≈..ß...™..◊ËÕ....................................................................................................................................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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μ«— Õ¬à“ßÀ¡“¬‡≈¢ ÚÙ

 “√∫≠— ®¥∑–‡∫’¬π

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

«—π∑.Ë’ ................ ‡™à“ √«¡ Õß‚©π¥ 𓬠°. Ò››››› › (≈ß™ÕË◊ ) 𓬠 .
‡¥Õ◊ π............... (¡’°”Àπ¥............ª)ï
æ.». .................

«—π∑’Ë................. ª≈Õ¥°“√‡™“à 𓬠¢. 𓬠°. Ò››››› › (≈ß™ÕË◊ ).........................
‡¥◊Õπ............... ºŸ‡â ™“à
æ.». ................. ∑Ë¥’ ‘π·ª≈ßπæÈ’ πâ ®“°°“√‡™“à μ“¡ ≠— ≠“‡™“à
∑’Ë¥π‘ √«¡ Õß‚©π¥ ©∫∫— ≈ß«π— ∑.Ë’ .................
‡¥Õ◊ π................æ.». .... μ“¡∫—π∑÷°¢Õâ μ°≈ß
ª≈Õ¥°“√‡™à“ ©∫—∫≈ß«π— ∑.’Ë .....‡¥Õ◊ π............
æ.». ....

Û¯Ò

Û¯Ú

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

∑’Ë «π/‰√à

∑’Ëπ“

∑.Ë’ .............

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

∑’Ë¥‘π·ª≈ß∑Ë’·¬°‰ªπÈ’ âæπ®“°°“√‡™à“μ“¡ —≠≠“·∫à߇™à“ Ë∑’ ‘¥π © —∫∫≈ß«—π∑Ë’...........‡¥◊Õπ..................æ.». .... μ“¡∫—π∑÷°¢âÕμ°≈ߪ≈Õ¥°“√‡™à“ ·≈–°“√ Õ∫ «π ‘∑∏‘„π∑¥’Ë π‘ ª√–‡¿∑...·..∫..àß..·...¬..°..„.π...π..“..¡..‡..¥..¡‘....(.ª..≈...Õ..¥..°...“..√..‡.™..“à..) ·¬° Ò ·≈–
©∫—∫≈ß«—π∑Ë’...........‡ ◊¥Õπ..................æ.». ....  à«π·ª≈ߧ߇À≈◊Õ°“√‡™à“§ß¡’Õ àŸ¬μ“¡‡¥‘¡
√μ–”«·“Àß.π..àß..∑..Ë’¥...‘π..............5..1..3..6...I.V....7..2..2..8..›..1.........................................μ”∫≈...................................................................·..ª...≈..ß..§..ß..‡.À...≈..◊Õ...
‡®â“æπ—°ß“π ’Ë∑ ‘¥π
‡≈¢∑Ë¥’ ‘π.............................Ò........................................................Õ”‡¿Õ........................................................................................

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

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

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

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

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

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

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

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

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

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

‚ ¥ À¡“â ¬ §à Ÿ ¡√ ™◊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“â ¢Õ· ¥ß√“§“∑√—æ¬å∑Ë’¢Õ∑”π‘μ°‘ √√¡π‡È’ ªìπ‡ß‘π........................ı....,.............................∫“∑.........›........... μ“ߧå

ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à (Àâ“À¡Ë◊π∫“∑∂â«π)

(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. ‡ªìπ√“§“∑’·Ë ∑â®√‘ß
(Û) .·..∫..ßà..·..¬...°..„.π...π..“..¡..‡.¥...¡‘ ....(.ª..≈...Õ..¥..°...“.√..‡..™..à“..)..μ...“..¡..§..”..¢..Õ...≈..ß..«..π— ..∑...Ë’ ........‡..¥..Õ◊ ..π.....................æ...»....................................................

(Ù) .....................................................................................................................................................................

(ı) .....................................................................................................................................................................

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

≈ß™Õ◊Ë ......................................................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........5..51..13..36.6..I.V.I.V...7.72..2..28..8›..›1..1..........‡≈¢∑’Ë¥‘π.................Ò..............................Àπâ“ ”√«®.........Û..ÚÙ...ı...........................

‚©π¥∑¥Ë’ π‘ ‡≈¢∑Ë’....................ˆ..Ú.Ò..ÛÚ..Û.Û..Ò.....................‡≈à¡.......................ˆ.Ò..Û............................Àπ“â ..................Û.Û.Ò.Û.............................

®”π«π∑¥Ë’ π‘ ............................Ò.Ò.........................‰√.à .............................›...................ß“π..............................›.›...................μ“√“ß«“
§ß‡À≈Õ◊ ................................Ò..Ò.........................‰√.à .............................››...................ß“π.............................›..›...................μ“√“ß«“

Û) ‰¥®â ¥∑–‡∫¬’ π·≈«â ·μ«à π— ∑.Ë’ ................................‡¥Õ◊ π............................................æ.»......................

≈ß™◊ÕË .......................................................

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

‡®â“æπ—°ß“π∑Ë’¥‘π

μ—«Õ¬à“ßÀ¡“¬‡≈¢ Úı Û¯Û

(∑.¥. ˘)

§”¢Õ..·..∫...àß..·..¬..°...„.π..π...“.¡...‡.¥..‘¡....(.ª...≈..Õ..¥...°..“..√..‡.™“à )

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

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

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

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

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

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¬Ë◊π§”¢ÕμàÕ‡®â“æπ—°ß“π∑Ë¥’ ‘π®—ßÀ«—¥....................................................¥â«¬§«“¡ μ— ¬å®√ß‘ «à“ :-
¢Õâ Ò. ¥«â ¬....¢..â“..æ..‡.®..“â..¡...™’ ..ÕË◊ ..‡.ª...πì ..º..∂Ÿâ...◊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®..–..

·...∫..àß..·..¬...°..„.π...π..“..¡..‡.¥...¡‘ ..∑..¥’Ë...‘π..·..ª...≈..ß..π..ÕÈ’...Õ..°..®..“..°..°...—π..‡.ª...ìπ...Ò....·..ª...≈..ß....‚.¥..¬...„.À..â∑...Ë¥’ ..π‘..·...ª..≈..ß..·...¬..°..‡.ª...πì ..‚.©...π..¥..„..À..¡...à .æ..πâ...®..“..°..°..“..√..‡.™..à“..μ...“.¡... ..—≠...≠....“.·...∫..ßà..‡.™...à“.∑...’¥Ë . π‘
©...∫..∫—...≈..ß..«..π— ..∑...Ë’ .....‡.¥...Õ◊ ..π.........................æ....».......... ..”..À..√..—∫...·..ª..≈...ß..§..ß..‡.À...≈..Õ◊..¬...—ß..§..ß..¡..°’...“.√..‡..™..“à..Õ..¬..μŸà...“..¡.. ..≠—...≠....“.‡..™..à“..‡.¥..‘¡....´..ßË÷..¢...“â .æ...‡.®..â“..®..–..‰..¥..πâ..”..™..à“..ß..·..º...π..∑..Ë’.....
∑...”..°..“..√..√..ß— ..«..—¥..ª..í°...À..≈..—°...‡.¢..μ..„..À..‡â.ª...πì ..°..“..√..·..π...πà ..Õ..π...μ..àÕ..‰..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..Õà...‰.ª..¥...«â ..¬...·...≈..–..¢..“â..æ...‡.®..“â..¢..Õ......
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.§..“à ..∏..√..√..¡..‡.π...’¬..¡..μ...“..¡..√..–..‡.∫...’¬..∫...............................................................................................................................................................

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

Û¯Ù

μ«— Õ¬“à ßÀ¡“¬‡≈¢ Úı

(∑.¥. Òˆ)

∫π— ∑÷°¢âÕμ°≈ߪ≈Õ¥°“√‡™à“

∑’Ë¥‘π
√–«“ß.............5..1.3..6....I.V....7..2..2..8..›.1...........................................μ”∫≈........................................................................
‡≈¢∑¥’Ë ‘π.................Ú...Û...........Àπâ“ ”√«®..........Ù..Ù................Õ”‡¿Õ.......................................................................
‚©π¥À¡“¬‡≈¢∑.’Ë ..............ı..Û...˘..Ò.........................................®ß— À«¥— .......................................................................

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

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

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

.....................π..“..¬....°........º..Ÿâ.„.À..‡â..™..à“....................................................

Õ“¬.ÿ ..ı.....,..Û.........ªï ‡™Õ◊È ™“μ‘............................... —≠™“μ.‘ .......‰..∑..¬..,...‰.∑..¬...........∫¥‘ “/¡“√¥“™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 .............................
¢//Õ//ª//Ø//‘≠//“/≥///μ//π//·/≈//–//„/À//∂â //âÕ//¬/§//”//μ/Õà//.....‰..¥..â∑...”.∫...π— ..∑..÷°...¢..Õâ ..μ...°..≈..ß..μ..àÕ...‡.®..“â..æ..π...°— ..ß..“..π..∑...¥Ë’ ..‘π.....................................................................................

¥//«â//¬//§//«/“/¡// //μ—//¬//å®/√//ß‘ / ¥ß— μàÕ‰ªπ’È :›
......................¢..âÕ....Ò......∑...Ë’¥..π‘...·..ª...≈..ß..‡..§..√..Ë◊Õ...ß..À..¡...“..¬..¢...â“..ß..∫..π...π..È’..¢..“â..æ...‡.®..â“....π..“..¬....¢.....‰.¥...‡â .™..“à..∑...¥’Ë ..π‘...‰.«..°â..∫—.....π..“..¬....°.....μ..“..¡... ..—≠...≠....“..‡.™..“à..∑...Ë¥’ ..π‘....©...∫..—∫...≈..ß...«..—π..∑...Ë’ ....
.‡.¥..Õ◊...π...............................æ....»...............∫..¥—...π..È’..¢..“â..æ...‡.®..“â..∑...Èß— .. ..Õ...ß..Ω..É“..¬...‰.¥...âμ..°...≈..ß..°...π— ..¬...π‘ ..¬..Õ...¡..„..À..∑â...¥Ë’ ..‘π...‡.©...æ..“..–.. ...«à ..π..∑...·Ë’ ..∫...àß..·..¬...°..Õ..Õ...°..‰..ª..‡..ª..πì...‚.©...π..¥...„.À..¡...à.‡..≈..¢...∑..’Ë..ˆ..Ú...Û..Û......
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......................¢..âÕ....Ú.......¢...Õ..„..À..‡â.®...“â ..æ..π...°— ..ß..“..π...∑..’Ë¥...‘π..®..¥...∑..–..‡..∫..¬’...π..„..À..μâ...“..¡..§...«..“..¡..ª...√..–.. ..ß...§..¥å...â«..¬....¢..â“..æ...‡.®..â“..¬..Õ...¡..‡.. ..¬’...§..“à..∏..√..√...¡..‡.π...’¬..¡...„.À...μâ ..“..¡...√..–..‡.∫...¬’ ..∫.........
......................∫...π— ..∑...°÷ ..¢..Õâ...μ..°...≈..ß..π...È’‰.¥...â∑..”..‰..«..Àâ..π...Ëß÷ ..©..∫...∫—....‡.°...Á∫..‰..«..â.≥..... ...”..π..°—...ß..“..π..∑...’Ë¥..π‘....¢..“â..æ...‡.®...“â ..∑..Èß—.. ...Õ..ß..Ω...“É ..¬..‰..¥..âμ...√..«..®..∫..—π...∑..÷°...¢..Õâ...μ..°..≈...ß....·..≈..–...‡.¢..“â..„..®.......
¢...âÕ..§...«..“..¡..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......“....¬.........¢......................................................º..⟇..™..à“............................................
............................................................................................≈..ß...™..Ë◊Õ...........................................................π......“....¬.........°......................................................º..âŸ.„.À...‡â .™..“à........................................
............................................................................................≈..ß...™..◊ËÕ....................................................................................................................................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¡“¬‡≈¢ Úı (√“¬°“√®¥∑–‡∫¬’ π·ª≈߇¥‘¡‚©π¥∑¥Ë’ ‘π‡≈¢∑Ë’ ÒÛı)

 “√∫≠— ®¥∑–‡∫¬’ π

®¥∑–‡∫¬’ π ª√–‡¿∑°“√ ºŸâ„À â ≠— ≠“ ºâŸ√—∫ —≠≠“ ‡π◊ÈÕ∑Ë’¥‘π ‡πÈ◊Õ∑Ë’¥‘π √–«“ß ‡®â“æπ—°ß“π∑’Ë¥‘π
«π— ‡¥◊Õπ ªï ®¥∑–‡∫’¬π 𓬠°. μ“¡ ≠— ≠“ §ß‡À≈Õ◊ ‡≈¢∑Ë’¥‘π ≈ß≈“¬¡Õ◊ ™ÕË◊
‚©π¥∑¥’Ë ‘π„À¡à ª√–∑∫— μ√“
«—π∑’Ë................. ·∫à߇™“à ‰√à ß“π μ“√“ß ‰√à ß“π μ“√“ß
‡¥Õ◊ π............... (¡’°”Àπ¥ ∫‘ ª)ï «“ «“
æ.». .................
𓬠¢. Ú› › › › › › (≈ß™ÕË◊ ) 𓬠 .
º‡âŸ ™“à

«π— ∑.’Ë ................ ·∫ßà ·¬°„ππ“¡‡¥‘¡ 𓬠°. 𓬠°. Ò › › Ò › › 5136 IV 7228-1 (≈ß™Ë◊Õ).........................
‡¥◊Õπ............... (ª≈Õ¥°“√‡™à“)
æ.». ................. ∑’Ë¥‘π·ª≈ß∑·’Ë ¬°‰ªπÈæ’ πâ ®“°°“√‡™à“μ“¡ Ò
 ≠— ≠“·∫à߇™à“ ©∫—∫≈ß«π— ∑Ë.’ ......‡¥◊Õπ............. ˆÚÛÛ
æ.». .... μ“¡∫—π∑°÷ ¢âÕμ°≈ߪ≈Õ¥°“√‡™“à

©∫—∫≈ß«—π∑Ë’......‡¥◊Õπ...................æ.». ....

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

Û¯ˆ

μ—«Õ¬“à ßÀ¡“¬‡≈¢ Úˆ (∑.¥. Ò)

∑∫’Ë “â π

∑Ë’ «π/‰√à

∑’Ëπ“

∑.’Ë .............

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

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

√μ–”«·“Àß.π..àß..∑..Ë’¥...‘π..............5..1..3..6...I.V....7..2..2..8..›..1.........................................μ”∫≈...................................................................·..ª...≈..ß..§..ß..‡..À..≈..◊Õ...

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

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

’∑Ë¥‘π·ª≈ß∑Ë’·¬°‰ªπ’È·≈–·ª≈ߧ߇À≈◊Õ°“√‡™à“¬—ߧߡ’Õ àŸ¬μ“¡ —≠≠“‡™à“∑Ë’ ‘¥π ©∫—∫≈ß«—π∑’Ë...........‡ ◊¥Õπ..................æ.». .... ‚©π¥∑¥Ë’ π‘
‡®â“æπ—°ß“π Ë’∑ ‘¥π ‡≈¢∑’Ë.....................Ò..Û..ı...................‡≈à¡........................................Àπâ“....................................

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

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

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

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

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

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

Õ¬Ÿà∑’∫Ë “â π/À¡àŸ∫“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 ºŸ.â ..∂..◊Õ...°..√..√..¡.. ...‘∑..∏..Ï‘...............

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

‚ ¥ À¡“â ¬ § àŸ ¡√ ™ÕË◊ ....................................................... ≠— ™“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ⓢշ ¥ß√“§“∑√—æ¬å∑’Ë¢Õ∑”π‘μ°‘ √√¡πÈ’‡ªπì ‡ßπ‘ ........................ı....,.............................∫“∑.........›........... μ“ߧå

ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à (Àâ“À¡Ëπ◊ ∫“∑∂«â π)

(Ò) ¢â“懮Ⓣ¡à‰¥√â —∫‚Õπ·∑πÀ√◊Õ‡æË◊Õª√–‚¬™πå·°à∫ÿ§§≈μà“ߥ“â «

(Ú) √“§“∑√—æ¬å∑Ë’· ¥ß‰«â„π Ù. ‡ªπì √“§“∑Ë·’ ∑®â √‘ß
(Û) .·..∫..ßà..·..¬...°..„.π...π..“..¡..‡.¥...‘¡....(.§..√..Õ...∫..°..“..√..‡.™..“à..)...μ..“..¡...§..”..¢..Õ..≈...ß..«..—π..∑..Ë.’ .........‡.¥...Õ◊ ..π.....................æ...»....................................................

(Ù) .....................................................................................................................................................................

(ı) .....................................................................................................................................................................

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

≈ß™◊ÕË ......................................................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........5..51..13.3.6.6..I.V.I.V...7.72..2..28..8›..›1.1...........‡≈¢∑’Ë¥π‘ ................Ò...............................Àπ“â  ”√«®.........Û..ÚÙ...ı...........................

‚©π¥∑’¥Ë π‘ ‡≈¢∑.’Ë ...................ˆ..Ú.Ò..ÛÚ..Û.Û..Ò.....................‡≈¡à .......................ˆ.Ò..Û............................Àπâ“.................Û..Û.Ò.Û.............................

®”π«π∑¥Ë’ π‘ ...........................Ò..Ò.........................‰√.à .............................›...................ß“π.............................›..›...................μ“√“ß«“
§ß‡À≈Õ◊ ................................Ò..Ò.........................‰√.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¡“¬‡≈¢ Úˆ Û¯˜

(∑.¥. ˘)

§”¢Õ..·..∫...àß..·..¬..°...„.π..π...“.¡...‡.¥..‘¡....(.§...√..Õ..∫...°..“..√..‡.™à“)

©∫—∫∑.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 ‡™ÕÈ◊ ™“μ.‘ ............................ —≠™“μ.‘ ............................∫¥‘ “/¡“√¥“™ËÕ◊ .....................................................................

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

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

¢Õ¬πË◊ §”¢ÕμàÕ‡®“â æπ°— ß“π∑¥’Ë π‘ ®ß— À«—¥....................................................¥â«¬§«“¡ —쬮å √‘ß«à“ :-
¢âÕ Ò. ¥â«¬....¢..“â ..æ..‡.®..â“..¡...™’ ..Ë◊Õ..‡.ª...πì ..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®..–..

·...∫..ßà..·..¬...°..„.π...π..“..¡..‡.¥...‘¡..∑..’Ë¥...‘π..·..ª...≈..ß..π..’ÈÕ...Õ..°..®..“..°..°...π— ..‡.ª...ìπ...Ò....·..ª...≈..ß....‚.¥..¬...„.À..∑â...Ë¥’ ..π‘..·...ª..≈..ß..·...¬..°..‡.ª...πì ..‚.©...π..¥..„..À..¡...à .·..≈..–...·..ª..≈..ß...§..ß..‡.À...≈..◊Õ..¬..ß—...§..ß..¡..°’...“.√..‡..™..“à ..Õ..¬..àŸ
μ...“..¡.. ..—≠....≠...“..‡.™..à“..∑..¥’Ë...‘π...©...∫..—∫...≈..ß..«..π— ..∑..Ë.’ ......‡.¥...◊Õ..π.........................æ...»...........´..÷Ëß..¢..“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“..æ...‡.®..â“..μ..“..¡..§...«..“..¡..ª..√..–.. ...ß..§..åμ..Õà...‰.ª...¥..«â..¬....·..≈..–..¢..â“..æ...‡.®..â“......
¢...Õ..√..∫—..√..Õ...ß..«..à“...∂..â“..∑..’Ë¥...π‘ ..√..“..¬..π..’¡È...’‡.¢..μ...§..≈..“..¥...‡.§..≈...◊ÕË ..π..¥...«â .¬...ª..√..–..°..“..√..„..¥..Ê....¢..â“..æ..‡.®..â“..¬..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

μ«— Õ¬à“ßÀ¡“¬‡≈¢ Úˆ Û¯¯

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

®¥∑–‡∫¬’ π ª√–‡¿∑°“√ ºâŸ„À â ≠— ≠“ ºâŸ√—∫ —≠≠“ ‡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.’ ................ ‡™“à (¡°’ ”Àπ¥ ∫‘ ªï) 𓬠°. 𓬠¢. Ú››››› › (≈ß™ËÕ◊ ) 𓬠 .
‡¥Õ◊ π............... ºŸ‡â ™à“
æ.». .................

«—π∑’Ë................. ·∫àß·¬°„ππ“¡‡¥‘¡ 𓬠°. 𓬠°. Ò › › Ò › › 5136 IV 7228-1 (≈ß™◊ÕË ).........................
‡¥◊Õπ............... (§√Õ∫°“√‡™“à )
æ.». ................. ∑¥’Ë π‘ ·ª≈ß∑Ë·’ ¬°‰ªπ·’È ≈–·ª≈ߧ߇À≈Õ◊ Ò
°“√‡™“à ¬—ߧߡ’Õ¬μŸà “¡ ≠— ≠“‡™“à ∑Ë’¥π‘ ˆÚÛÛ
©∫—∫≈ß«π— ∑.’Ë ......‡¥◊Õπ....................æ.». ....

μ«— Õ¬“à ßÀ¡“¬‡≈¢ Úˆ

 “√∫≠— ®¥∑–‡∫’¬π

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

®¥∑–‡∫’¬π ª√–‡¿∑°“√ ºŸâ„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.’ ................ ‡™à“ (¡’°”Àπ¥ ∫‘ ª)ï 𓬠°. 𓬠¢. Ò››››› › (≈ß™ËÕ◊ ) 𓬠 .
‡¥◊Õπ............... (§√Õ∫°“√‡™à“) ºŸâ‡™à“ «π— ∑Ë.’ .......................
æ.». ................. °“√‡™“à ¬ß— §ß¡Õ’ ¬μŸà “¡ ≠— ≠“‡™“à ∑¥Ë’ ‘𠇥◊Õπ......................
©∫∫— ≈ß«π— ∑Ë’.......‡¥◊Õπ....................æ.». .... æ.». ........................
(≈ß™Õ◊Ë )..................

Û¯˘

Û˘

μ—«Õ¬à“ßÀ¡“¬‡≈¢ Ú˜ (∑.¥. Ò)
∑∫’Ë “â π

∑’ Ë «π/‰√à

∑’Ëπ“

∑Ë.’ .............

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

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

μ”·Àπàß∑’Ë¥‘π (§√Õ∫›ª≈Õ¥°“√‡™“à ) ·¬° Ò

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

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

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

∑Ë’¥‘π·ª≈ß∑’Ë·¬°‰ªπ’Èæâπ®“°°“√‡™à“μ“¡ —≠≠“‡™à“ ’Ë∑ ‘¥π ©∫—∫≈ß«—π∑Ë’...........‡ ◊¥Õπ..................æ.». ....‚©π¥∑Ë¥’ ‘π
μ“¡∫—π∑÷° â¢Õμ°≈ߪ≈Õ¥°“√‡™à“ © —∫∫≈ß«—π∑’Ë...........‡ ◊¥Õπ..................æ.». .... ‡≈¢∑Ë’.....................Ò..Û..ı...................‡≈à¡............Ò..Ù..........................Àπ“â ....ı...Ò.............................

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

Ò. ¢“â 懮⓺Ÿ¡â 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„Àâ∂âÕ¬§”¥â«¬§«“¡ —쬮å √ß‘ ∂“â ¢“â 懮ⓄÀ∂â 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 ºâŸ...∂..Õ◊..°...√..√..¡.. ..‘∑...∏..Ï‘ ...............

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

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

Õ¬∑Ÿà ∫’Ë “â π/À¡Ÿ∫à “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 ºâŸ...∂...Õ◊ ..°..√..√..¡.. ...‘∑..∏..‘Ï...............

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

‚ ¥ À¡“â ¬ §Ÿ à ¡√ ™ÕË◊ ....................................................... ≠— ™“μ.‘ ......................

Õ¬àŸ∑Ë∫’ “â π/À¡àŸ∫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‘ °‘ √√¡π‡È’ ªπì ‡ß‘π........................ı....,.............................∫“∑.........›........... μ“ߧå

ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à (Àâ“À¡π◊Ë ∫“∑∂â«π)

(Ò) ¢“â 懮“â ‰¡à‰¥â√—∫‚Õπ·∑πÀ√◊Õ‡æÕË◊ ª√–‚¬™πå·°∫à §ÿ §≈μ“à ߥ“â «

(Ú) √“§“∑√æ— ¬∑å Ë·’  ¥ß‰«â„π Ù. ‡ªìπ√“§“∑·Ë’ ∑®â √ß‘
(Û) .·..∫..àß..·..¬...°..„.π...π..“..¡..‡.¥...‘¡....(.§..√..Õ...∫..›..ª..≈...Õ..¥..°...“.√..‡..™..à“..)..μ...“..¡..§..”..¢..Õ...≈..ß..«..—π..∑...’Ë ........‡..¥..◊Õ..π.....................æ...».........................................

(Ù) .....................................................................................................................................................................

(ı) .....................................................................................................................................................................

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

≈ß™◊ËÕ......................................................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..51..13..36.6..I.V.I.V..7..72..2..28..8›..›1..1..........‡≈¢∑¥Ë’ π‘ .................Ò..............................Àπâ“ ”√«®.........Û..ÚÙ...ı...........................

‚©π¥∑’¥Ë ‘π‡≈¢∑Ë’....................ˆ..Ú.Ò..ÛÚ..Û.Û..Ò.....................‡≈à¡.......................ˆ.Ò..Û............................Àπ“â ..................Û.Û.Ò.Û.............................

®”π«π∑¥’Ë π‘ ............................Ò.Ò.........................‰√.à .............................›...................ß“π..............................›.›...................μ“√“ß«“
§ß‡À≈Õ◊ ................................Ò..Ú.........................‰√.à .............................››...................ß“π.............................›..›...................μ“√“ß«“

Û) ‰¥®â ¥∑–‡∫’¬π·≈â«·μ«à —π∑Ë.’ ................................‡¥Õ◊ π............................................æ.»......................

≈ß™Ë◊Õ.......................................................

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

‡®â“æπ—°ß“π∑Ë’¥‘π

Û˘Ò

μ—«Õ¬à“ßÀ¡“¬‡≈¢ Ú˜ (∑.¥. Ò)
∑∫Ë’ “â π

∑ Ë’ «π/‰√à

∑Ë’π“

∑Ë.’ .............

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

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

μ”·Àπàß∑’Ë¥‘π (§√Õ∫›ª≈Õ¥°“√‡™à“) ·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«¥— ........................................................................................

’Ë∑¥‘π·ª≈ß∑Ë’·¬°‰ªπ’È·≈–·ª≈ߧ߇À≈◊Õ°“√‡™à“¬—ߧߡ’Õ Ÿà¬μ“¡ —≠≠“‡™à“∑Ë’¥‘π ©∫—∫≈ß«—π∑’Ë...........‡ ◊¥Õπ..................æ.». ....‚©π¥∑Ë’¥‘π
‡®â“æπ—°ß“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¡âŸ π’ “¡μÕà ‰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 âÕ¬§”¥â«¬§«“¡ μ— ¬®å √‘ß ∂“â ¢â“懮ⓄÀâ∂Õâ ¬§”‰¡‡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 ºŸâ...∂..◊Õ..°...√..√..¡.. ..‘∑...∏..Ï‘ ...............

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

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

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

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

‚ ¥ À¡“â ¬ §à Ÿ ¡√ ™ËÕ◊ ....................................................... —≠™“μ.‘ ......................

Õ¬Ÿà∑Ë’∫â“π/À¡àŸ∫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‘ ........................ı....,.............................∫“∑.........›........... μ“ߧå

ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à (À“â À¡◊πË ∫“∑∂â«π)

(Ò) ¢â“懮“â ‰¡à‰¥â√∫— ‚Õπ·∑πÀ√◊Õ‡æÕË◊ ª√–‚¬™π·å °∫à §ÿ §≈μà“ߥ“â «

(Ú) √“§“∑√—æ¬∑å ’Ë· ¥ß‰«â„π Ù. ‡ªìπ√“§“∑·Ë’ ∑®â √ß‘
(Û) .·..∫..àß..·..¬...°..„.π...π..“..¡..‡.¥...‘¡....(.§..√..Õ...∫..›..ª..≈...Õ..¥..°...“.√..‡..™..“à ..)..μ...“..¡..§..”..¢..Õ...≈..ß..«..π— ..∑...’Ë ........‡..¥..Õ◊ ..π.....................æ...».........................................

(Ù) .....................................................................................................................................................................

(ı) .....................................................................................................................................................................

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

≈ß™ÕË◊ ......................................................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..51..13.3.6.6..I.V.I.V...7.72..2..28..8›..›1.1...........‡≈¢∑’Ë¥π‘ .................Ò....Ò..........................Àπ“â  ”√«®.........Û..ÚÙ...ˆ...........................

‚©π¥∑Ë’¥‘π‡≈¢∑Ë.’ ...................ˆ..Ú.Ò..ÛÚ..Ù.Û..Ò.....................‡≈¡à ........................ˆÒ..Û............................Àπâ“.................Û..Û.Ò.Ù.............................

®”π«π∑¥’Ë π‘ ...........................Ò..Ò.........................‰√.à .............................›...................ß“π.............................›..›...................μ“√“ß«“
§ß‡À≈Õ◊ ................................Ò..Ò.........................‰√.à .............................››...................ß“π.............................›..›...................μ“√“ß«“

Û) ‰¥®â ¥∑–‡∫’¬π·≈â«·μà«π— ∑’Ë.................................‡¥Õ◊ π............................................æ.»......................

≈ß™ËÕ◊ .......................................................

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

‡®â“æπ—°ß“π∑’Ë¥‘π

Û˘Ú

μ—«Õ¬“à ßÀ¡“¬‡≈¢ Ú˜

(∑.¥. ˘)

§”¢Õ.·..∫...ßà ..·..¬..°..„..π..π..“..¡..‡..¥..‘¡....(.§...√..Õ..∫..›..ª...≈..Õ..¥...°..“..√..‡.™..“à.)

©∫—∫∑.’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 ‡™Õ◊È ™“μ.‘ ............................ —≠™“μ.‘ ............................∫‘¥“/¡“√¥“™ËÕ◊ .....................................................................

Õ¬àŸ∑∫’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 ......................

¢Õ¬◊Ëπ§”¢ÕμÕà ‡®“â æπ°— ß“π∑’Ë¥‘π®—ßÀ«—¥....................................................¥«â ¬§«“¡ —μ¬å®√ß‘ «“à :-
¢âÕ Ò. ¥«â ¬...¢...â“.æ...‡.®..â“..¡..™’...ÕË◊ ..‡.ª...ìπ..º..âŸ∂...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..ÈÕ’...Õ..°..®..“..°..°...π— ..‡.ª...ìπ...Ú.....·..ª..≈...ß...‚.¥...¬..∑..’Ë¥...‘π..·..ª...≈..ß..·..¬...°..∑..Ë’..Ò...„..À..æâ..âπ...®..“..°..°..“..√..‡.™..“à.... ..”..À..√..∫—...·..ª..≈...ß..·..¬..°..∑...’Ë .Ú....·..≈...–......
·...ª..≈..ß..§...ß..‡.À...≈..◊Õ..°..“..√..‡.™...“à ..¬..ß— ..§..ß..¡...Õ’ ..¬..Ÿμà...“.¡... ..≠—...≠...“..‡..™..“à ..∑..¥Ë’..‘π....©..∫...—∫..≈..ß...«.π—...∑..Ë.’......‡.¥..◊Õ...π...................æ...»...........´..ßË÷ ..¢..“â..æ..‡..®..“â ..®..–..‰.¥..πâ...”..™..“à ..ß..·..º..π..∑...Ë∑’ ..”..°..“..√..√..ß—..«..—¥..
ª...í°..À..≈...—°..‡.¢..μ...„.À...â‡.ª..πì...°..“..√..·..π..πà...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“..æ...‡.®..“â ..μ..“..¡..§...«..“.¡...ª..√..–.. ...ß..§..μå..àÕ...‰.ª...¥..â«..¬....·..≈..–..¢..â“..æ...‡.®..“â......
¢...Õ..√..—∫..√..Õ...ß..«..“à ...∂..“â..∑..¥’Ë...π‘ ..√..“..¬..π..¡’È...’‡.¢..μ...§..≈..“..¥...‡.§..≈...◊ËÕ..π..¥...â«.¬...ª..√..–..°..“..√..„..¥..Ê....¢..â“..æ..‡.®..“â..¬..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...“..¬...°........................ ºâŸ¢Õ
........................................................ 欓π
........................................................ 欓π

μ«— Õ¬à“ßÀ¡“¬‡≈¢ Ú˜ Û˘Û

(∑.¥. Òˆ)

∫—π∑÷°¢âÕμ°≈ߪ≈Õ¥°“√‡™“à

∑’Ë¥‘π
√–«“ß.............5..15..31.6.3..6.I.V.I.V..7..27..2..82..›8..1›..1........................................μ”∫≈........................................................................
‡≈¢∑Ë¥’ π‘ ..................Ú..ÒÛ...........Àπâ“ ”√«®........Û..Ù.Ù.Ù.Ù...............Õ”‡¿Õ.......................................................................
‚©π¥À¡“¬‡≈¢∑’Ë..........Ò...Û..ı..Û...˘..Ò.........................................®—ßÀ«—¥.......................................................................

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

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

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

.....................π..“..¬....°........º..âŸ.„.À..‡â..™..“à ....................................................

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

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

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

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μ«— Õ¬“à ßÀ¡“¬‡≈¢ Ú˜ Û˘Ù

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

®¥∑–‡∫¬’ π ª√–‡¿∑°“√ ºŸâ„À â ≠— ≠“ ºŸâ√—∫ —≠≠“ ‡πÈ◊Õ∑’Ë¥‘π ‡π◊ÈÕ∑’Ë¥‘π √–«“ß ‡®â“æπ—°ß“π∑’Ë¥‘π
«—𠇥◊Õπ 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 ................ ‡™à“ (¡’°”Àπ¥ ‘∫ª)ï 𓬠°. 𓬠¢. Û››››› › (≈ß™◊ËÕ) 𓬠 .
‡¥◊Õπ............... ºŸ‡â ™“à
æ.». .................
«π— ∑Ë’................. ·∫àß·¬°„ππ“¡‡¥¡‘ 𓬠°. 𓬠°. Ò › › Ú › › 5136 IV 7228-1 (≈ß™ÕË◊ ).........................
‡¥Õ◊ π............... (§√Õ∫›ª≈Õ¥
æ.».................. °“√‡™à“) ∑¥Ë’ ‘π·ª≈ß∑·’Ë ¬°‰ªπ’æÈ âπ®“°°“√‡™à“μ“¡ Ò
 ≠— ≠“‡™à“∑’Ë¥‘π ©∫—∫≈ß«—π∑.’Ë ......‡¥◊Õπ............ ˆÚÛÛ
æ.». .... μ“¡∫—π∑°÷ ¢Õâ μ°≈ߪ≈Õ¥°“√‡™à“

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

Ò››Ò›› 5136 IV 7228-1 (≈ß™ÕË◊ ).........................
∑Ë’¥‘π·ª≈ß∑’·Ë ¬°‰ªπÈ·’ ≈–·ª≈ߧ߇À≈◊Õ ÒÒ
°“√‡™à“¬ß— §ß¡Õ’ ¬μŸà “¡ ≠— ≠“‡™“à ∑’¥Ë ‘π ˆÚÛÙ
©∫—∫≈ß«—π∑.’Ë ......‡¥◊Õπ....................æ.». ....

À¡“¬‡Àμÿ  “√∫≠— ®¥∑–‡∫’¬π·ª≈ß·¬° ‚©π¥‡≈¢∑Ë’ ˆÚÛÛ ª≈Õ¥°“√‡™à“ ‰¡μà Õâ ߬°√“¬°“√®¥·®ßâ ·μàÕ¬“à ß„¥

μ«— Õ¬“à ßÀ¡“¬‡≈¢ Ú˜

 “√∫—≠®¥∑–‡∫’¬π

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

®¥∑–‡∫¬’ 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 ................ ‡™à“ (¡’°”Àπ¥ ∫‘ ªï) 𓬠°. 𓬠¢. Ò››››› › (≈ß™ÕË◊ ) 𓬠 .
‡¥Õ◊ π............... (§√Õ∫°“√‡™“à ) ºŸ‡â ™à“ «—π∑’Ë........................
æ.». ................. °“√‡™“à ¬—ߧߡՒ ¬Ÿàμ“¡ ≠— ≠“‡™à“∑’Ë¥‘𠇥◊Õπ......................
©∫∫— ≈ß«—π∑.Ë’ ......‡¥Õ◊ π....................æ.». .... æ.». ........................
(≈ß™ËÕ◊ )..................

Û˘ı

Û˘ˆ

μ«— Õ¬“à ßÀ¡“¬‡≈¢ Ú¯ μ“¡√–‡∫’¬∫¢Õâ Ò˘ (Ò) «√√§ÀπËß÷ (∑.¥. 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–”«·“Àß.π..àß..∑..Ë’¥...‘π..............5..1..3..6...I.V....7..2..2..8..›..1.........................................μ”∫≈..........(..§..√..Õ..∫...°..“..√..‡.™..à“..)...................................·..ª...≈..ß..§..ß..‡.À...≈..◊Õ...

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

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

’∑Ë¥‘π·ª≈ß∑Ë’·¬°‰ªπ’È·≈–·ª≈ߧ߇À≈◊Õ°“√‡™à“¬—ߧߡ’Õ Ÿ¬àμ“¡ —≠≠“‡™à“∑Ë’ ‘¥π ©∫—∫≈ß«—π ’Ë∑...........‡ ◊¥Õπ..................æ.». ....‚©π¥∑’¥Ë π‘
‡®â“æπ—°ß“π ’Ë∑¥‘π ‡≈¢∑Ë.’ ....................Ò..Û..ı...................‡≈¡à ............Ò..Ù..........................Àπâ“....ı................................

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

Ò. ¢â“懮⓺Ÿ¡â ’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∂âÕ¬§”¥â«¬§«“¡ —μ¬å®√ß‘ ∂“â ¢â“懮“â „À∂â 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 ºŸ.â ..∂..Õ◊..°...√..√..¡.. ..∑‘...∏..‘Ï ...............

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

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

Õ¬Ÿ∑à ∫Ë’ â“π/À¡Ÿ∫à “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 º.⟠..∂..Õ◊...°..√..√..¡.. ...‘∑..∏..‘Ï...............

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

‚ ¥ À¡“â ¬ §à Ÿ ¡√ ™◊ËÕ....................................................... ≠— ™“μ.‘ ......................

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

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

ı. ¢“â 懮“â ¢Õ√∫— √Õß«“à (À“â À¡◊Ëπ∫“∑∂«â π)

(Ò) ¢“â 懮Ⓣ¡à‰¥√â ∫— ‚Õπ·∑πÀ√Õ◊ ‡æ◊ÕË ª√–‚¬™π·å °à∫ÿ§§≈μà“ߥ⓫

(Ú) √“§“∑√æ— ¬∑å Ë’· ¥ß‰«â„π Ù. ‡ªπì √“§“∑·Ë’ ∑®â √‘ß
(Û) .·..∫..ßà..·..¬...°..„.π...π..“..¡..‡.¥...¡‘ ....(.§..√..Õ...∫..°..“..√..‡.™..“à..)...μ..“..¡...§..”..¢..Õ..≈...ß..«..π— ..∑...’Ë .........‡.¥...Õ◊ ..π.....................æ...»....................................................

(Ù) .....................................................................................................................................................................

(ı) .....................................................................................................................................................................

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

≈ß™ÕË◊ ......................................................º âŸ 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..51..13.3.6.6..I.V.I.V...7.72..2..28..8›..›1.1...........‡≈¢∑Ë’¥π‘ ................Ò...............................Àπ“â  ”√«®.........Û..ÚÙ...ı...........................

‚©π¥∑’Ë¥π‘ ‡≈¢∑’.Ë ...................ˆ..Ú.Ò..ÛÚ..Û.Û..Ò.....................‡≈à¡.......................ˆ.Ò..Û............................Àπ“â .................Û..Û.Ò.Û.............................

®”π«π∑¥’Ë π‘ ...........................Ò..Ò.........................‰√.à .............................›...................ß“π.............................›..›...................μ“√“ß«“
§ß‡À≈Õ◊ ................................Ò..Ò.........................‰√.à .............................››...................ß“π.............................›..›...................μ“√“ß«“

Û) ‰¥â®¥∑–‡∫’¬π·≈â«·μà«—π∑.Ë’ ................................‡¥Õ◊ π............................................æ.»......................

≈ß™ËÕ◊ .......................................................

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

‡®â“æπ—°ß“π∑Ë’¥‘π

μ—«Õ¬à“ßÀ¡“¬‡≈¢ Ú¯ μ“¡√–‡∫¬’ ∫¢Õâ Ò˘ (Ò) «√√§Àπ÷Ëß

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

®¥∑–‡∫¬’ 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’ ................ ‡™à“ (¡°’ ”Àπ¥ ∫‘ ª)ï 𓬠°. 𓬠¢. Ú› › › › › › (≈ß™ÕË◊ ) 𓬠 .
‡¥◊Õπ............... º‡âŸ ™“à
æ.». .................

«—π∑.Ë’ ................ ·∫ßà ·¬°„ππ“¡‡¥‘¡ 𓬠°. 𓬠°. Ò › › Ò › › 5136 IV 7228-1 (≈ß™ÕË◊ ).........................
‡¥◊Õπ............... (§√Õ∫°“√‡™“à )
æ.». ................. ∑’¥Ë π‘ ·ª≈ß∑Ë·’ ¬°‰ªπÈ·’ ≈–·ª≈ߧ߇À≈◊Õ Ò
°“√‡™“à ¬—ߧߡ’Õ¬àŸμ“¡ —≠≠“‡™“à ∑¥Ë’ π‘ ˆÚÛÛ
©∫—∫≈ß«—π∑Ë’.......‡¥Õ◊ π....................æ.». ....

Û˘˜

μ—«Õ¬à“ßÀ¡“¬‡≈¢ Ú˘ μ“¡√–‡∫¬’ ∫¢âÕ Ò˘ (Ò) «√√§ÀπßË÷ Û˘¯

 “√∫≠— ®¥∑–‡∫’¬π

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

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

«—π∑’Ë................. ‡™“à (¡°’ ”Àπ¥ ∫‘ ª)ï 𓬠°. 𓬠¢. Ú››››› › (≈ß™◊ËÕ) 𓬠 .
‡¥Õ◊ π............... (§√Õ∫°“√‡™“à ) ºâŸ‡™à“ «π— ∑’.Ë ............................
æ.». ................. °“√‡™“à ¬—ߧߡՒ ¬àμŸ “¡ —≠≠“‡™à“∑’Ë¥‘𠇥◊Õπ..........................
©∫—∫≈ß«—π∑.Ë’ ......‡¥Õ◊ π....................æ.». .... æ.». ..........................
(≈ß™◊ËÕ)......................