คู่มือการปฏิบัติงาน กระบวนการจดทะเบียนสิทธิและนิติกรรม ประเภทจำนอง (ปี 2553)

˜´ª°¥nµŠ®¤µ¥Á¨… ÓÕ (š.—. Ú)
‡µÎ …°..Á.ž..¨..¸É¥..œ.....°Éº ..Ÿ..o¦¼ .´...‹..µÎ .œ...°..Š..........
(‡n„¼ ¦–¸¤µ…°‹—š³Á¥¸ œš´ÊŠ­°Š iµ¥)
(¦³®ªnµŠ„·‹„µ¦š¸ÁÉ ž}œœ˜· ·‡» ‡¨Á—¥¸ ª„œ´ )

Œ´š.¸É ......................................

š—ɸ œ·
¦³ªµŠ.........................................................………....................˜Îµ¨.......……….…..…................................................
Á¨…š.¸É ......................................®œoµ­Îµ¦ª‹.........................…………..................°ÎµÁ£°.…………….........................…..
̜—®¤µ¥Á¨…š.ɸ .......................................……………………......‹´Š®ª´—.....................………………………………

›œµ‡µ¦ Á° „‹· „µ¦ª·Áš«›œ„‹· ­µ…µ„¦ªŠ» œ´Ášš¡É¸..².....…….......Á—°º œ..............………................¡.«.........….........
…µo ¡Á‹oµ.......›...œ..µ..‡..µ..¦...Á.°........................………………………….…….……† †††† ††††† †† † °µ
¥»..................že Á°Êº µ˜·...........……..............­´ µ˜·.........………….............—· µ/¤µ¦—µÉ°º ..............……….............................
°¥š¼n ¸Éoµœ/®¤n¼ oµœ...................................Á¨…š.¸É .……................˜¦°„/Ž°¥……………………™œœ………………....®¤n¼š¸É...........
˜Îµ¨/…ªŠ.………...............°ÎµÁ£°/Á…˜......………...............‹Š´ ®ª´—...………….................®¤µ¥Á¨…Ú¦«¡´ šr......……………..
…°¥œºÉ ‡Îµ…°˜n°Á‹µo ¡œ„´ Šµœš—¸É ·œ‹´Š®ª´—...........................…….........................—ªo ¥‡ªµ¤­´˜¥‹r ¦·Šªnµ:-
…°o Ò. —oª¥..…...oµ.¡...Á.‹..oµ....›..œ...µ..‡…µ¦…Á…° …„·‹…„µ…¦ª…·Áš…«›…œ…„·‹…­.µ..…..µ..„..¦..Š»..Á.š...¡...²...Â..¨...³..›..œ...µ..‡..µ..¦...Á.°...Ÿ...¼o‹..´—..˜...Ê´Š..„..·‹..„...µ..¦..ª..·Á.š...«..›...œ..„...·‹..—..´.Š.„...¨..nµ..ª...
.Ž..¹ÉŠ..š...´ÊŠ..­...°..Š.. ..iµ..¥..¤...¸“..µ..œ...³..Á.ž...}œ...œ...·˜..·...»‡..‡...¨..Á.—...¸¥..ª..„..´œ...˜...µ.¤…„…‘®…¤…µ¥…¤…¸‡ª..µ..¤..ž...¦..³..­...Š..‡..r…...°..Ä..®...o¡...œ...´„..Š..µ..œ...Á.‹..oµ..®...œ..oµ..š...¸ÉÁ.ž...¨..ɸ¥..œ......ɺ°..Ÿ..o¼.¦..´..‹...ε.œ...°...Š.š...ɸ—...·œ....
.Â..ž...¨..Š..…..oµ..Š..˜..oœ....˜...µ.¤...­...´ ......µ..‹..µÎ .œ...°...Š.¨...Š..ª..´œ...š..…¸É....…....…....Á…—°º …œ……….………………...…¡.…«..….......‹..µ..„...›..œ...µ.‡...µ.¦....Á.°...„..‹·...„..µ..¦..ª..·Á.š...«..›..œ...„..·‹...­..µ..…..µ..„..¦...»Š.Á.š...¡...².....
.Á.ž..}œ...›...œ..µ..‡...µ.¦....Á.°...Ã..—...¥..Á.®...˜..»š...¸É.›..œ...µ..‡..µ..¦...Á.°....„..·‹..„...µ..¦..ª.…·Áš…«›…œ„…·‹…­µ……µ…„¦…»ŠÁ…š¡…²...Å...—..o—...µÎ .Á.œ...·œ...„..µ..¦..Ã..°...œ...­..·œ...š...¦..´¡...¥..rÂ..¨...³..®...œ...¸Ê­..·.œ..…...°..Š..„...·‹..„..µ..¦......
.ª..·Á.š..«...›..œ...„..‹·..Å..ž...¥..´Š..„...‹· ..„..µ..¦..…..°...Š..›..œ...µ.‡...µ..¦...Á.°...Â..¨...oª......………………........................................................................................................

..........................................................................…………………………........................................................................................

..........................................................................…………………………........................................................................................

..........................................................................………………………….........................................................................…............

..........................................................................………………………….........................................................................…............
…o° Ó. Œ³œÊœ´ …°Ä®Áo ‹µo ¡œ´„ŠµœšÉ¸—·œ..—..µÎ..Á.œ...·œ...„..µ..¦..Á.ž...¨..¥¸É…œ...°ºÉ...Ÿ..¦o¼..´...‹..µÎ..œ...°..Š..˜..µ..¤...­..´.......µ.‹..ε..œ...°..Š..—...´Š..„..¨..nµ..ª..Ä..®...oÁ.ž...}œ.....°ºÉ ...›...œ.…µ‡…µ¦..Á…°

.˜..µ..¤..‡...ª..µ.¤...ž...¦..³..­...Š..‡..r—..ªo...¥...Ä.œ...„...µ.¦...œ..ʸÅ..—...o ...°..„..„...¨..nµ..ª..„..µ…¦Á…ž¨…ɸ¥œ……°ºÉ Ÿ…¼¦o ´…‹…圅°Š…Ä®...o¨..¼„...®..œ...¸ÊÂ...¨..³..Ÿ..‹¼o...µÎ .œ...°...Š.š...¦..µ.....Â..¨..ªo.........................................

..........................................................................………………........................................................................................................

..........................................................................…………………………........................................................................................

..........................................................................…………………………........................................................................................

..........................................................................………………………….........................................................................…............
›œµ‡µ¦ Á° „‹· „µ¦ª·Áš«›œ„·‹­µ…µ„¦»ŠÁš¡²
……................……›.œ...µ.‡...µ.¦....Á.°.......................Ÿo¼…°
................…….....….…........…..................¡¥µœ
..................……….........……......................¡¥µœ

˜´ª°¥nµŠ®¤µ¥Á¨… ÓÕ
­µ¦´ ‹—š³Á¥¸ œ

ÁœÊº°š—¸É ·œ ÁœºÊ°š¸É—·œ ¦³ªµŠ Á‹µo ¡œ´„Šµœš¸É—·œ
Á¨…š—ɸ œ· ¨Š¨µ¥¤°º °ºÉ
‹—š³Á¥¸ œ ž¦³Á£š„µ¦ ŸÄo¼ ®o­´µ Ÿ¦¼o ´ ­´ µ ˜µ¤­´µ ‡ŠÁ®¨°º
ªœ´ Á—º°œ že ‹—š³Á¥¸ œ ̜—šÉ—¸ œ· Ä®¤n ž¦³š´ ˜¦µ
›œµ‡µ¦ Á° „·‹„µ¦ Ŧn Šµœ ˜µ¦µŠ Ŧn Šµœ ˜µ¦µŠ
ªÁ· š«›œ„‹· ­µ…µ ªµ ªµ
„¦Š» Áš¡²
ªœ´ šÉ¸…………. ‹µÎ œ°ŠÁž}œž¦³„´œ œµ¥ „. --- --- - (¨ŠºÉ°)……………
Á—°º œ…………
¡.«. …………

ªœ´ šÉ¸…………. Áž¨¥¸É œºÉ°Ÿo¦¼ ´ ›œµ‡µ¦ Á° „‹· „µ¦ ›œµ‡µ¦ Á° ------ - (¨ŠÉ°º )……………
Á—º°œ………… ‹Îµœ°Š (¦³®ªµn Š ª·Áš«›œ„‹· ­µ…µ
¡.«. ………… „·‹„µ¦šÁɸ žœ} „¦Š» Áš¡²
œ˜· ·»‡‡¨Á—¥¸ ª„´œ)

˜´ª°¥µn Š®¤µ¥Á¨… ÓÖ ˜µ¤¦³Á¸¥…o° ÓÚ (Ò) † š¸Éµo œ (š.—. Ò)

† š­É¸ ªœ/Ŧn
¨³„µ¦­°­ª‡œÎµ…­°·š‹›—Ä· œšš³Á¸É—œ· ¥¸ œž­¦š·³Á›£Â· š¨³...œÂ..˜·..nŠ.„· .….¦.µ.¦.¥.¤..(…‡¦…°…‹µÎ…œ°…Š)…..†††......šœš. ɜɸ¸°..„µ..Á.…...˜......
˜µÎ ®œnŠšÉ—¸ œ· † ĜÁ…˜

¦³ªµŠ...................5..1..3..6..I..V....7..2..2..8..-.1…..........................................……..˜µÎ ¨.........................................……......….....................................................…..
Á¨…š¸É—œ· .......................Ö...........................................………............…°ÎµÁ£°.....................................…...........................................……....................…..
®œµo ­µÎ ¦ª‹...................Ø...×.............................................……..............‹Š´ ®ª´—...........................................................................................……........…….
̜—š¸É—·œ
Á¨…š.¸É ........................Ø...Ô...×...............................……..........................Á¨¤n ..........……Ù…..………........................®œµo ......………….Ô…×..…...……......…..
šÉ¸—·œÂž¨ŠšÉ¸Â¥„ÅžœÊ¸Â¨³Âž¨Š‡ŠÁ®¨º°„µ¦‹Îµœ°Š¥´Š‡Š¤¸°¥n¼˜µ¤­´µ‹Îµœ°ŠŒ´¨Šª´œš¸É………..Á—º°œ…………¡.«……..‹µÎ œªœš—ɸ ·œ.................Ö...................…....................Ŧn.....………………- ……….....................Šµœ.................…………- …...….................…....˜µ¦µŠªµ
Á‹oµ¡œ´„Šµœš¸É—·œ
Ò. …µo ¡Á‹µo Ÿ¤¼o ¸œµ¤˜°n ޜʸ ¤‡¸ ªµ¤ž¦³­Š‡…r °‹—š³Á¸¥œ­·š›·Â¨³œ˜· „· ¦¦¤Á„ɸ¥ª„´ °­Š´ ®µ¦¤· š¦´¡¥rš¸„É ¨µn ª…oµŠœœÊ¸ ¨³Å—ož’·µ–˜œÂ¨oª
…°Ä®™o °o ¥‡µÎ —oª¥‡ªµ¤­˜´ ¥‹r ¦Š· ™µo …oµ¡Á‹oµÄ®™o o°¥‡µÎ ŤÁn žœ} ‡ªµ¤‹¦·ŠÄ®očo™°o ¥‡µÎ œ¥¸Ê ´œ…µo ¡Á‹µo ĜšµŠ‡—°¸ µµÅ—o

Á¨…ž¦³‹µÎ ˜´ªž¦³µœ

Ó. …µo ¡Á‹µo ..................œ..µ..¥...„.......……..................... † †††† ††††† †† † Ÿo¼ ....…...µ.¥...……….....….....…..

°µ¥» .............................. že ­´ µ˜· ..............................…Ś…¥ ……............. ·—µ / ¤µ¦—µº°É ........................................................................…......…..
† í— † ®¤oµ¥ † ‡­n¼ ¤¦­°ºÉ .................………….......…...............…............…...........……
°¥n¼š¸Éoµœ/®¤n¼ oµœ ..................……....... Á¨…šÉ¸ ........................ ˜¦°„/Ž°¥ ...........…...…................. ™œœ ..….......……..….....….....®¤n¼šÉ¸ ..…......……
˜Îµ¨/…ªŠ .....................….............°µÎ Á£°/Á…˜ ..............…….................. ‹´Š®ª—´ ..........….…...........…........®¤µ¥Á¨…Ú¦«¡´ šr .............…............…

Á¨…ž¦³‹µÎ ˜´ªž¦³µœ
Ô. …µo ¡Á‹oµ ...........œ...µ.¥...Š....……............................... † †††† ††††† †† † Ÿ¼o ....Ž..°Êº....…............…..……..

°µ¥» .............................. že ­´ µ˜· .....….............Å..š...¥..................... ·—µ / ¤µ¦—µ°ºÉ ...............………............................…................…...........…..…
† í— † ®¤µo ¥ † ‡­¼n ¤¦­ºÉ° .....................……....................­´ µ˜· ………..…...…….........……
°¥n¼š¸Éµo œ/®¤¼n µo œ ................................ Á¨…šÉ¸ .....……............ ˜¦°„/Ž°¥ ..................……............. ™œœ ................……...…..........®¤nš¼ ɸ ...…......…...

˜Îµ¨/…ªŠ ................................. °ÎµÁ£°/Á…˜ ................……..................‹´Š®ª´— ......……......….…..............®¤µ¥Á¨…Ú¦«¡´ šr ..............….......…....
Õ. …oµ¡Á‹oµ…°Â­—Š¦µ‡µš¦¡´ ¥šr ¸É…°šµÎ œ·˜·„¦¦¤œÁʸ žœ} ÁŠ·œ ..................Ò..,.Ñ...Ñ.…Ñ,Ñ…Ñ.Ñ......................... µš ....…….......…-............­˜µŠ‡r
(®œÉŠ¹ ¨oµœµš™oªœ)
Ö. …oµ¡Á‹oµ…°¦´ ¦°Šªµn

(Ò) …oµ¡Á‹oµÅ¤Ån —¦o ´Ã°œÂšœ®¦º°Á¡ºÉ°ž¦³Ã¥œr„n ‡» ‡¨˜µn Š—µo ª

(Ó) ¦.Å.µ.¤.‡.n¤.µ..š¸­...¦ŠÉ· ..ž¡´ ..¨¥...šr¼„..­¸ÂÉ...­¦..oµ—..Š.Š.Å...ª..Äo ..œ...Õ......Á..ž..œ}...¦..µ..‡..µ..š...¸ÂÉ ..š..…o‹¦…Š· ….........................................................................................…...................……
(Ô)
(Õ) .Ÿ..o¼…...µ.¥..Å...—..šo...—ɸ ..œ·...¤..µ..Ã..—...¥..…....…....…......Á.ž...œ} ..Á.ª...¨..µ..…....…....…......ž..e..Å.…¤n‡…µo Š…µ.Î .¦..³..£...µ..¬..¸...ε..¦..»Š..š...°o ..Š..š...ɸ .................................................…...............……
(Ö) .Ÿ..o¼…...µ.¥..Å..—...o¦..´.....µÎ..¦..³..¦..µ..‡..µ..š...¸É—..œ·...‡..¦.....™...oª..œ...Â..¨..ªo................………....................................................................…..........…...............……
ª´œš.¸É ................. Á—º°œ ...............................…........ ¡.«. ...........…….......
¨Š°ºÉ ..........................œ...µ..¥...„......................... Ÿ…¼o ° …µ¥
¨Š°ºÉ ..........................œ...µ..¥...Š......................... Ÿo…¼ ° Ž°Êº
¨ŠÉ°º ........................................................... Ÿ­o¼ °­ªœ

(………………………………………)

­Îµ®¦´¡œ´„ŠµœÁ‹oµ®œoµš¸É

Ò) ¦µ‡µž¦³Á¤œ· šœ» š¦´¡¥.r .......................................………........……………...................………….µš..........…….…….............…..............­˜µŠ‡r
Ó) ̜—š¸É—·œÄ®¤¦n ³ªµŠ..............5..1..3.…6I…V7.2..2..8..-..1...........Á¨…š¸—É œ· ..........…....……×…….......……..........®œµo ­µÎ ¦ª‹....................…؅؅……...............

̜—š¸—É ·œÁ¨…š.ɸ ........Ø...Ô...Ø.........……................….....Á¨n¤.................…………Ù.......................……..®œµo …………………..…Ô…Ø….………………
‡‹ÎµŠœÁ®ª¨œ°º š..—ɸ..·œ.............................ÒÕ..............…......................….……………...........….…............ÅŦ¦n.n.........................…..………...............….………--………………..............................….....ŠŠµµœœ...................…....….…..…...........……....…--.........…..........................˜˜µµ¦¦µµŠŠªªµµ
Ô) ŗo‹—š³Á¸¥œÂ¨ªo ˜nª´œš.ɸ ..............…...............Á—º°œ...............................¡.«. ……………….

¨ŠÉº° ..................................................................
( .............................................................. )
Á‹oµ¡œ´„ŠµœšÉ¸—œ·

˜ª´ °¥µn Š®¤µ¥Á¨… ÓÖ ˜µ¤¦³Á¸¥ …°o ÓÚ (Ò) (¦µ¥„µ¦‹—š³Á¸¥œ ž¨ŠÁ—·¤ ̜—š¸É ØÔ×)
­µ¦´ ‹—š³Á¥¸ œ

Áœ°Êº šÉ—¸ œ· ÁœºÊ°š¸—É ·œ ¦³ªµŠ Á‹µo ¡œ´„ŠµœšÉ¸—·œ
Á¨…š¸É—œ· ¨Š¨µ¥¤°º ºÉ°
‹—š³Á¥¸ œ ž¦³Á£š„µ¦ ŸÄo¼ ®­o ´µ Ÿ¦¼o ´ ­´ µ ˜µ¤­´ µ ‡ŠÁ®¨°º
ªœ´ Á—°º œ že ‹—š³Á¥¸ œ œµ¥ „. ̜—š—¸É ·œÄ®¤n ž¦³š´ ˜¦µ
œµ¥ …. Ŧn Šµœ ˜µ¦µŠ Ŧn Šµœ ˜µ¦µŠ
œµ¥ „. Ÿo¦¼ ´‹µÎ œ°Š ªµ ªµ

ª´œš…ɸ ……….. ‹µÎ œ°Š Ö-- --- - (¨ŠÉº°) œµ¥ ¡.
Á—°º œ………….
¡.«. …………. œµ¥ Š. Ò - - Õ - - 5136 IV 7228 - 1 (¨Šº°É )……………

ª´œšÉ¸ …………. nŠ…µ¥ š¸É—·œÂž¨ŠšÉ¸Â¥„ÅžœÊ¸Â¨³Âž¨Š‡ŠÁ®¨°º „µ¦‹Îµœ°Š¥´Š‡Š¤¸°¥n¼ ×
Á—º°œ…………. (‡¦°‹µÎ œ°Š) ˜µ¤­´µ‹Îµœ°ŠŒ´¨Šª´œš…¸É ..Á—°º œ………....¡.«…… ØÔØ
¡.«. ………….

­ªn œÂž¨Š‡ŠÁ®¨°º ‡Š¤¸„µ¦‹Îµœ°Š˜µ¤Á—¤·

˜ª´ °¥µn Š®¤µ¥Á¨… Ó× ˜µ¤¦³Á¸¥ …°o ÓÚ (Ò) ª¦¦‡­°Š (¦µ¥„µ¦‹—‹oŠš¸É—œ· ž¨ŠšÂ¸É ¥„ŞĮ¤n̜—š¸É ØÔØ)
­µ¦´‹—š³Á¥¸ œ

ÁœºÊ°šÉ—¸ ·œ Áœº°Ê š—¸É œ· ¦³ªµŠ Á‹oµ¡œ´„Šµœš—¸É ·œ
Á¨…š—¸É œ· ¨Š¨µ¥¤º°Éº°
‹—š³Á¥¸ œ ž¦³Á£š„µ¦ Ÿ¼oÄ®­o ´µ Ÿ¦o¼ ´­´ µ ˜µ¤­´ µ ‡ŠÁ®¨°º ž¦³š´˜¦µ
ªœ´ Á—°º œ že ‹—š³Á¥¸ œ œµ¥ „. ̜—š¸É—·œÄ®¤n
œµ¥ …. Ŧn Šµœ ˜µ¦µŠ Ŧn Šµœ ˜µ¦µŠ (¨Šº°É ) œµ¥ ¡.
Ÿ¼o¦´ ‹µÎ œ°Š ªµ ªµ ª´œš…¸É ..Á—°º œ……..
¡.«……
ªœ´ š¸É…………. ‹µÎ œ°Š Ò- - --- - (¨Š°Éº )……………
Á—º°œ………… (‡¦°‹µÎ œ°Š)
¡.«. ………… „µ¦‹Îµœ°Š¥Š´ ‡Š¤°¸ ¥˜n¼ µ¤­´µ‹µÎ œ°ŠŒ´ ¨Šª´œš…ɸ ….
Á—°º œ…………..¡.«……..

˜´ª°¥µn Š®¤µ¥Á¨… ÓØ ˜µ¤¦³Á¥¸ …°o ÓÚ (Ó) † š¸Éoµœ (š.—. Ò)

† šÉ¸­ªœ/Ŧn
¨³„µ¦­°­ª‡œÎµ…­°š· ‹›—·Äœšš³Á—ɸ ·œ¸¥œž­¦·š³Á›£Â· š¨³...œ..˜·.Â..·„..¦.nŠ.¦Â..¤.¥.…„Äœ…œ…µ¤…Á—…¤· …...†††......œššÉ¸œÉ¸°..„µ..Á.…...˜......
˜µÎ ®œnŠšÉ—¸ ·œ
(‡¦° - ž¨°—‹Îµœ°Š) † ĜÁ…˜ Â¥„ Ò

¦³ªµŠ...........................5..1..3..6...I.V....7.…22.8..-.1......................................……..˜Îµ¨.........................................……......….....................................................…..
Á¨…š—¸É ·œ...............................Ó....Ô...............................………............…°µÎ Á£°.....................................…...........................................……....................…..
®œµo ­Îµ¦ª‹.........................Õ...Õ...Õ....................................……..............‹Š´ ®ª´—...........................................................................................……........…….
̜—š¸É—·œ
Á¨…š.¸É ...........................Ö....Ô...Ú..Ò.........................……..........................Á¨¤n ..........……Ö…Õ..………........................®œoµ......………….Ú…Ò..…...……......…..
‹µÎ œªœšÉ—¸ œ· .................Ó...................…....................Ŧn.....………………Ô……….....................Šµœ.................…………ÖÑ…...….................…....˜µ¦µŠªµ

šÉ¸—·œÂž¨ŠšÉ¸Â¥„Åžœ¸Ê¡oœ‹µ„„µ¦‹Îµœ°Š˜µ¤­´µ‹Îµœ°Š Œ´¨Šª´œš¸É…..Á—º°œ………¡.«…… Ò. …µo ¡Á‹µo Ÿo¼¤œ¸ µ¤˜n°ÅžœÊ¸ ¤¸‡ªµ¤ž¦³­Š‡…r °‹—š³Á¥¸ œ­š· ›·Â¨³œ˜· „· ¦¦¤Á„ɸ¥ª„´ °­´Š®µ¦·¤š¦¡´ ¥šr ¸É„¨µn ª…oµŠœœ¸Ê ¨³Å—ož’·µ–˜œÂ¨ªo
˜µ¤´œš¹„…o°˜„¨Šž¨°—‹Îµœ°Š ¨Šª´œš¸É….Á—º°œ………¡.«…… …°Ä®™o o°¥‡µÎ —ªo ¥‡ªµ¤­˜´ ¥r‹¦·Š ™µo …oµ¡Á‹oµÄ®o™o°¥‡µÎ ŤÁn ž}œ‡ªµ¤‹¦·ŠÄ®očo™o°¥‡ÎµœÊ¸¥´œ…oµ¡Á‹µo ĜšµŠ‡—°¸ µµÅ—o

Á‹oµ¡œ´„Šµœš¸É—·œ Á¨…ž¦³‹Îµ˜´ªž¦³µœ

Ó. …µo ¡Á‹µo ..................œ..µ..¥...„........……..................... † †††† ††††† †† † Ÿ¼o ...…...°.....……….....….....…..

°µ¥» ............Ö...Ñ............... že ­´ µ˜· ..............................…Ś…¥……............. —· µ / ¤µ¦—µÉ°º ........................................................................…......…..
† í— † ®¤oµ¥ † ‡­¼n ¤¦­É°º .................………….......…...………...........…............…...........……
°¥š¼n ɝ¸ oµœ/®¤n¼ oµœ ..................……....... Á¨…š¸É ........................ ˜¦°„/Ž°¥ ...........…...…................. ™œœ ..….......……..….....….....®¤¼šn ɸ ..…......……
˜µÎ ¨/…ªŠ .....................….............°µÎ Á£°/Á…˜ ..............…….................. ‹Š´ ®ª—´ ..........….…...........…........®¤µ¥Á¨…Ú¦«¡´ šr .............…............…
Á¨…ž¦³‹µÎ ˜ª´ ž¦³µœ
Ô. …oµ¡Á‹oµ ..................œ...µ.¥…„…. ............................... † †† † Ÿo¼ ...…..°.....…............…..……..
†††† †††††

°µ¥» ............Ö...Ñ............... že ­´µ˜· .....….....Å..š...¥............................. ·—µ / ¤µ¦—µÉº° ...............………............................…................…...........…..…
† í— † ®¤µo ¥ † ‡n¼­¤¦­É°º .....................……....................­´µ˜· ………..…...…….........……
°¥¼nš¸É µo œ/®¤¼n µo œ ................................ Á¨…šÉ¸ .....……............ ˜¦°„/Ž°¥ ..................……............. ™œœ ................……...…..........®¤šn¼ ¸É ...…......…...

˜Îµ¨/…ªŠ ................................. °µÎ Á£°/Á…˜ ................……..................‹Š´ ®ª—´ ......……......….…..............®¤µ¥Á¨…Ú¦«¡´ šr ..............….......…....

Õ. …oµ¡Á‹oµ…°Â­—Š¦µ‡µš¦¡´ ¥ršÉ¸…°šµÎ œ·˜·„¦¦¤œ¸ÁÊ žœ} ÁŠœ· .........................…….......................... µš ....…….......…............­˜µŠ‡r

Ö. …µo ¡Á‹oµ…°¦´ ¦°Šªnµ

(Ò) …µo ¡Á‹oµÅ¤Ån —¦o ´Ã°œÂšœ®¦º°Á¡Éº°ž¦³Ã¥œÂr „n»‡‡¨˜nµŠ—oµª

(Ó) ¦.Â.µ..‡..Šnµ..š..¥.¦.„.´¡.Ä.¥.œ..rš.œ.¸É..µ.­.¤.—.Á.—.Š.Å.¤· ..ª.˜.Äo ..œµ.¤..Õ.‡..µÎ...…Á..ž°..}œ.Œ..¦..µ.´.‡..¨µ..šŠ..ª.ɸ .´œ.š..š…‹o ¦…¸É …·Š……Á—..º°...œ...…....…...…....…......¡.....«...…....…......................................................…...................……
(Ô)
(Õ) ..............................................................................……….................................................................................…...............……
(Ö) ..............................................................................………....................................................................…..........…...............……
ª´œš.¸É ................. Á—º°œ ...............................…........ ¡.«. ...........…….......
¨ŠºÉ° ........................œ...µ..¥...„........................... Ÿ…¼o °
¨ŠÉ°º ........................œ...µ..¥...„............................ Ÿo…¼ °
¨Š°Éº ........................................................... Ÿo¼­°­ªœ

(………………………………………)

­µÎ ®¦´ ¡œ„´ ŠµœÁ‹oµ®œµo š¸É

Ò) ¦µ‡µž¦³Á¤·œšœ» š¦´¡¥.r .......................................………........……………...................………….µš..........…….…….............…..............­˜µŠ‡r
Ó) ̜—š¸É—œ· Ä®¤¦n ³ªµŠ..............5..1..3.…6 I…V7..2..2..8..-..1..........Á¨…š—ɸ ·œ..........…....……Ó…Õ….......……..........®œµo ­µÎ ¦ª‹....................…Õ…ÕÖ………...............

̜—š¸É—·œÁ¨…š.¸É .......................Ö…Ô…ÚÓ................….....Á¨n¤.................…………Ö....Õ...................……..®œoµ…………………..…Ú…Ó….………………

‹Îµœªœš¸É—·œ....................….........…- ……......….......Ŧn...............……......……Ô………....................Šµœ...............……....…..Ö....Ñ..…...........˜µ¦µŠªµ
‡ŠÁ®¨º°.........................................Ó………......….....Ŧn.............……..........……- ………..............….Šµœ.........…….........…..…-..................˜µ¦µŠªµ

Ô) ŗo‹—š³Á¥¸ œÂ¨oªÂ˜nª´œš.¸É ..............…...............Á—°º œ...............................¡.«. ……………….
¨Š°Éº ...................................................................
( ................................................................ )
Á‹oµ¡œ´„ŠµœšÉ¸—œ·

˜´ª°¥µn Š®¤µ¥Á¨… ÓØ ˜µ¤¦³Á¥¸ …°o ÓÚ (Ó) † šÉ¸ µo œ (š.—. Ò)
† š­¸É ªœ/Ŧn
¨³„µ¦­°­ª‡œÎµ…­°š· ‹›—Ä· œšš³Á—ɸ ·œ¥¸ œž­¦š·³Á›£·Âš¨³...œ..˜·.Â..·„..¦.Šn .¦Â..¤.¥.…„Äœ…œ…µ¤…Á—…¤· …..†††......ššœ. ¸œ¸ÉÉ°..„µ..Á.…...˜......
˜µÎ ®œnŠšÉ¸—·œ
(‡¦° - ž¨°—‹Îµœ°Š) † ĜÁ…˜ Â¥„ Ó Â¨³
¦³ªµŠ........................5..1..3..6...I.V....7..2..2…8-.1.........................................……..˜Îµ¨.........................................……......…........................................Â..ž..¨...Š..‡..Š..Á…®¨..°º
Á¨…š¸—É œ· ............................Ó....Ô..................................………............…°µÎ Á£°.....................................…...........................................……....................…..
®œµo ­µÎ ¦ª‹.........................Õ...Õ...Õ....................................……..............‹´Š®ª—´ ...........................................................................................……........…….
̜—š¸É—·œ
Á¨…š.¸É ...........................Ö....Ô...Ú..Ò.........................……..........................Á¨n¤..........……Ö…Õ..………........................®œoµ......………….Ú…Ò..…...……......…..

‹ÎµœªœšÉ—¸ ·œ.....................Ó...............…....................Ŧn.....………………- ……….....................Šµœ.................…………- …...….................…....˜µ¦µŠªµ

šÉ¸—·œÂž¨Šš¸ÉÂ¥„ÅžœÊ¸Â¨³Âž¨Š‡ŠÁ®¨º°„µ¦‹Îµœ°Š¥´Š‡Š¤¸°¥n¼˜µ¤­´µ‹Îµœ°ŠŒ´¨Šª´œšÉ¸…….Á—º°œ………….¡.«…… Ò. …µo ¡Á‹oµŸ¤¼o ¸œµ¤˜n°ÅžœÊ¸ ¤‡¸ ªµ¤ž¦³­Š‡…r °‹—š³Á¥¸ œ­·š›Â· ¨³œ˜· „· ¦¦¤Á„¥É¸ ª„´°­´Š®µ¦¤· š¦¡´ ¥rš¸É„¨µn ª…µo ŠœœÊ¸ ¨³Å—žo ’·µ–˜œÂ¨oª
Á‹oµ¡œ´„Šµœš¸É—·œ …°Ä®™o o°¥‡µÎ —oª¥‡ªµ¤­˜´ ¥‹r ¦Š· ™µo …oµ¡Á‹oµÄ®™o °o ¥‡µÎ ŤÁn ž}œ‡ªµ¤‹¦Š· Ä®očo™°o ¥‡Îµœ¸¥Ê œ´ …oµ¡Á‹µo ĜšµŠ‡—¸°µµÅ—o

Á¨…ž¦³‹µÎ ˜ª´ ž¦³µœ

Ó. …µo ¡Á‹µo ..................œ..µ..¥...„........……..................... † †††† ††††† †† † Ÿ¼o ....…...°....……….....….....…..

°µ¥» ............Ö...Ñ............... že ­´µ˜· ..............................…Ś…¥……............. —· µ / ¤µ¦—µÉ°º ........................................................................…......…..
† í— † ®¤µo ¥ † ‡n¼­¤¦­ºÉ° .................………….......…...………...........…............…...........……
°¥n¼š¸É oµœ/®¤¼noµœ ..................……....... Á¨…šÉ¸ ........................ ˜¦°„/Ž°¥ ...........…...…................. ™œœ ..….......……..….....….....®¤nš¼ ¸É ..…......……
˜µÎ ¨/…ªŠ .....................….............°ÎµÁ£°/Á…˜ ..............…….................. ‹´Š®ª—´ ..........….…...........…........®¤µ¥Á¨…Ú¦«´¡šr .............…............…

Á¨…ž¦³‹Îµ˜ª´ ž¦³µœ

Ô. …µo ¡Á‹µo ..................œ...µ.¥…„…. ............................... † †††† ††††† †† † Ÿ¼o ....…..°....…............…..……..

°µ¥» ............Ö...Ñ............... že ­´ µ˜· .....….....Å..š...¥............................. ·—µ / ¤µ¦—µ°ºÉ ...............………............................…................…...........…..…
† í— † ®¤oµ¥ † ‡n­¼ ¤¦­°Éº .....................……....................­´ µ˜· ………..…...…….........……
°¥n¼šÉ¸ oµœ/®¤¼n µo œ ................................ Á¨…š¸É .....……............ ˜¦°„/Ž°¥ ..................……............. ™œœ ................……...…..........®¤š¼n ¸É ...…......…...

˜Îµ¨/…ªŠ ................................. °ÎµÁ£°/Á…˜ ................……..................‹´Š®ª—´ ......……......….…..............®¤µ¥Á¨…Ú¦«´¡šr ..............….......…....

Õ. …µo ¡Á‹oµ…°Â­—Š¦µ‡µš¦´¡¥šr Ʌ¸ °šµÎ œ˜· ·„¦¦¤œÊÁ¸ žœ} ÁŠ·œ .........................……...-....................... µš ....…….......…............­˜µŠ‡r

Ö. …oµ¡Á‹oµ…°¦´ ¦°Šªnµ

(Ò) …µo ¡Á‹oµÅ¤Ån —¦o ´ ðœÂšœ®¦°º Á¡É°º ž¦³Ã¥œÂr „n »‡‡¨˜µn Š—oµª

(Ó) ¦.Â.µ..‡..nŠµ..š..¥.¦.„.´¡.Ä.¥.œ..rš.œ.¸ÂÉ..µ.­.¤.—.Á.—.Š.Å.·¤..ª.˜.oÄ..œµ.¤..Õ.‡..µÎ...…Á..ž°..}œ..Œ.¦..µ..‡´..µ.¨.š.Š..ɸª..šœ´..…o‹š¦…¸É …·Š .…Á—º°...œ...…....…...…....…........¡.....«...…....….......................................................…...................……
(Ô)
(Õ) ..............................................................................……….................................................................................…...............……
(Ö) ..............................................................................………....................................................................…..........…...............……
ª´œš.¸É ................. Á—°º œ ...............................…........ ¡.«. ...........…….......
¨Š°Éº .......................œ...µ..¥...„............................. Ÿ…o¼ °
¨ŠÉº° .......................œ...µ..¥...„............................ Ÿo¼…°
¨Š°Éº ........................................................... Ÿo­¼ °­ªœ

(………………………………………)

­Îµ®¦´¡œ„´ ŠµœÁ‹µo ®œµo š¸É

Ò) ¦µ‡µž¦³Á¤·œšœ» š¦¡´ ¥.r .......................................………........……………...................………….µš..........…….…….............…..............­˜µŠ‡r
Ó) ̜—š—ɸ œ· Ä®¤¦n ³ªµŠ..............5..1..3.…6 I…V7..2..2..8..-..1..........Á¨…š¸É—·œ..........…....……Ó…Ö….......……..........®œoµ­Îµ¦ª‹....................…Õ…Õ×………...............

̜—š¸É—œ· Á¨…š.ɸ .......................…Ö…ÔÚ..Ô..............….....Á¨n¤.................…………Ö....Õ...................……..®œoµ…………………..…Ú…Ô….………………

‹µÎ œªœš¸—É ·œ....................….........…Ò……......….......Ŧn...............……......……-………....................Šµœ...............……....…..-......…...........˜µ¦µŠªµ
‡ŠÁ®¨º°.........................................…Ò ……......….....Ŧn.............……..........……- ………..............….Šµœ.........…….........…..…- ..................˜µ¦µŠªµ

Ô) ŗ‹o —š³Á¸¥œÂ¨oªÂ˜nª´œš.ɸ ..............…...............Á—°º œ...............................¡.«. ……………….
¨Š°Éº ...................................................................
( ................................................................ )
Á‹µo ¡œ´„Šµœš—¸É œ·

˜ª´ °¥nµŠ®¤µ¥Á¨… ÓØ ˜µ¤¦³Á¥¸ …o° ÓÚ (Ó) (š.—. Ò×)

œ´ š„¹ …°o ˜„¨ŠÁ¦º°É Šž¨°—‹µÎ œ°Š

š¸—É œ·
¦³ªµŠ.......…5…13…6 I…V …72…28.-.1........................…..˜µÎ ¨...........……………………………..…………….............
Á¨…š¸É—œ· ………Ó…Ô…………®œµo ­Îµ¦ª‹......…Õ…Õ…Õ...............°µÎ Á£°..............…........……................................
̜—®¤µ¥Á¨…š…ɸ ……………Ö…Ô…ÚÒ………….……….‹´Š®ª´—................................…….…...........................
š¸Éªnµ„µ¦…………..….…………………………
ª´œš…ɸ ………Á—°º œ………….…….…¡.«. ……………

Á¨…ž¦³‹Îµ˜´ªž¦³µœ

…oµ¡Á‹µo ..……….....œ...µ.¥..........……Ÿ¼¦o …´ ‹..ε.…œ°..Š.......................………....... † †††† ††††† †† †
..……….....œ..µ..¥...„........……Ÿo‹¼ …εœ..°.…Š .........................………....... † †††† ††††† †† †

°µ¥» .........Ö...Ñ...,.՞Ñe ÁÊº°µ˜…· …Å…š¥…….…… ­´µ˜·.......Å..š...¥............... ·—µ / ¤µ¦—µÉº° ..........….….........................................
°¥nš¼ ɸµo œ/®¤n¼oµœ ...................... Á¨…šÉ¸ ................. ˜¦°„/Ž°¥ ....…….........….......... ™œœ ..........…….…………..®¤nš¼ ɸ .....…...
˜Îµ¨/…ªŠ ...................... °ÎµÁ£°/Á…˜ ............................ ‹´Š®ª—´ ...…......………................®¤µ¥Á¨…Ú¦«¡´ šr .….....................
…///°//ž//’///·//µ//–///˜//œ///Â//¨//³//Ä/®///o™//°o//¥//‡//Î/µ/˜//n°…Å…—šo …坅´œ…š¹„……°o…˜…„¨…Š˜…°n …Á‹oµ…¡…œ´„…Šµ…œš…¸É—…·œ……………………………………………………..
—///ªo //¥/‡///ª//µ/¤//­///´˜//¥//‹r //¦//·Š —´Š˜n°Åžœ¸Ê : -
………………o°…Ò…. ˜…µ¤…š…¸É…oµ…¡Á…‹oµ…šÊ´Š…­…°Š… iµ…¥Å…—o‹…—…š³…Á.…¸¥œ…‹µÎ …œ°…Š…š¸É—…·œ.Â…ž…¨Š…Á‡…¦Éº°…Š®…¤…µ¥……oµ…Š…œœ…ʸŅªo˜…n°„..…´œ …˜µ…¤®…œ…´Š­…º°­…´……µ .
…‹Îµœ…°…ŠŒ……´¨…Šª…´œ…šÉ¸…….…Á—…º°œ………….………...¡….«………………´—œ…¸Ê……oµ¡…Á‹…oµ œ…µ¥…„….Å…—o……°…¦´Š…ª´—.Â……nŠÂ…¥„…Ĝ…œ…µ¤…Á—…·¤Á…­¦…ȋÁ.¦.…¸¥…¦o°…¥…¡¦…o°¤…š…ɸ‹³….
…‹—…š³…Á…¸¥œ…Â…¨oª………oµ¡…Á‹…oµ œ…µ…¥ …. Ÿ…o¼¦…´‹…µÎ œ…°…Š¥…·œ¥…°¤…Ä.®…o‹…—š…³Á…¸¥…œ….…nŠÂ…¥„…Ĝ…œ…µ¤…Á—…·¤Ã…—…¥Ä…®oš…ɸ—…·œÂ…ž.¨.…ŠÂ…nŠ…Â…¥„…Ì…œ…—š…¸É—·œ….
…Á¨……š…¸É Ö…Ô…ÚÓ……¡oœ…‹…µ„…„µ…¦‹…µÎ œ…°.Š…‡…Š¤…¸„…µ¦…‹Îµ…œ°…Š‡…¦°……˜—·…°…¥nÁ¼ Œ…¡…µ³…š—ɸ …·œ…ž…¨Š.…Â¥…„Ã…Œ…œ—…Á¨……š…¸É Ö…Ô…ÚÔ…..Â…¨…³Â…ž¨…Š…‡Š…Á®…¨º°….
…Ì…œ—…Á¨……š…¸É Ö…Ô…Ú…Ò ˜…µ¤…®…œ´Š…­…°º ­…´ …µ…‹µÎ…œ…°Š…Œ…´ …¨Š.ª…´œ…š…¸É….….Á—…°º œ…….…………….¡….«……………Ş…˜µ…¤Á…—·¤………..……………………….
………………o°…Ó…. ……oµ¡…Á‹…µo š…ʊ´ …­°…Š .…µi ¥…˜„…¨Š…„œ´…¥…·œ¥…°…¤„…œ´ Ä…®…oÁ‹µo…¡…œ´„…Šµ…œš…ɸ—…·œ‹…—.š…³…Á¥¸…œ…Ä®……o oµ…¡…Á‹oµ…˜µ…¤…‡ª.µ.…¤ž…¦³…­…Š‡…r—´Š…„¨…nµª….
……oµ…Š˜…oœ ……………………………………………….……………….…………………………………..……………………….
……………´œ…š¹„………o°˜…„…¨Š…œ¸Êš…µÎ Å…ª.o®…œ…ɹŠŒ……´ …Á„ȝ…Å…ªo –……­Îµ…œ´„…Šµ…œ…š¸É—…·œ…š…´ÊŠ­…°Š… iµ.…¥Å…—o˜…¦ª…‹…—¼…´œ…š¹„……°o…˜…„¨..Š…¨…³…Á…oµ…ċ……°o…‡…ªµ…¤ .
…˜¨…°—…Â…¨oª…‹…¹Š¨…Š¨…µ¥…¤°º ……ºÉ°Å…ªÁo ž…}œ…®…¨„´ …“µ…œ˜…°n …®œ…oµ¡…¥.µ…œ…¨…³Á…‹µo ¡…œ…´„Š.…µœ…š…¸É—·œ…………………………..……………………….

………………………………….……………………………………………….…………………………..…………………….
……………………………………………………¨…Š.É°º……………………………….œ……µ…¥………. ……………………….Ÿ…¼o¦´…‹µÎ …œ°…Š…..……………………….
………………………………….…………………¨Š…°Éº…………………………………œ…µ…¥……„….…….………………….Ÿ…o¼‹µÎ …œ°…Š ………..…………………….
……………………………………………………¨…Š.ɺ°……………………………….……………………………………….¡…¥µ…œ ………..……………………….
………………………………….…………………¨Š…º°É …………………………………………………….………………….¡…¥µ…œ …………..…………………….

……………………………………………………….……………….…………………………………..……………………….
……………´œ…š„¹………°o ˜…„¨…Š…œ¸ÅÊ …—šo…ε˜.…°n ®…œ…oµ ……………………………………….…………………………..…………………….
……………………………………………………¨…Š.É°º……………………………….……………………………………….Á‹…µo ¡…œ…„´ Š…µœ…š.¸É—.…·œ …………………….
……………………………………………………….…ž…¦…³š…´…˜¦…µ˜.ε…®…œ…Šn Á…ž}œ…­…µÎ ‡…´ ………………..……………………….

………………………………….……………………………………………….…………………………..…………………….

……………………………………………………….……………….…………………………………..……………………….

………………………………….……………………………………………….…………………………..…………………….

˜´ª°¥nµŠ®¤µ¥Á¨… ÓØ ˜µ¤¦³Á¥¸ …o° ÓÚ (Ó) (¦µ¥„µ¦‹—š³Á¥¸ œ ž¨ŠÁ—·¤ ̜—šÉ¸ ÖÔÚÒ)
­µ¦´‹—š³Á¸¥œ

ÁœºÊ°šÉ—¸ œ· ÁœÊº°š—¸É ·œ ¦³ªµŠ Á‹µo ¡œ´„Šµœš¸—É ·œ
Á¨…šÉ¸—œ· ¨Š¨µ¥¤°º Éº°
‹—š³Á¸¥œ ž¦³Á£š„µ¦ Ÿo¼Ä®o­´µ Ÿ¦¼o ´­´µ ˜µ¤­´µ ‡ŠÁ®¨°º
ª´œ Á—º°œ že ‹—š³Á¸¥œ ̜—š¸—É ·œÄ®¤n ž¦³š´˜¦µ
œµ¥ . Ŧn Šµœ ˜µ¦µŠ Ŧn Šµœ ˜µ¦µŠ
Ÿ¼o¦´ ‹Îµœ°Š ªµ ªµ

ªœ´ šÉ¸…………. ‹Îµœ°Š œµ¥ „. Ó Ô ÖÑ --- - (¨ŠºÉ°) œµ¥ ¡.
Á—°º œ…………
¡.«. …………

ªœ´ šÉ¸ …………. Šn Â¥„Äœœµ¤Á—·¤ œµ¥ „. œµ¥ „. - Ô ÖÑ Ó - - 5136 IV 7228-1 (¨ŠÉº°)…………….

Á—º°œ………… (‡¦°-ž¨°—‹Îµœ°Š) šÉ—¸ ·œÂž¨Šš¸ÉÂ¥„Åžœ¸Ê¡œo ‹µ„„µ¦‹µÎ œ°Š˜µ¤­´ µ‹Îµœ°Š ÓÕ
¡.«. …………. Œ´ ¨Šª´œš…ɸ .Á—º°œ……..¡.«…..˜µ¤œ´ š¹„…o°˜„¨Š ÖÔÚÓ

ž¨°—‹µÎ œ°Š ¨Šª´œš…ɸ ..Á—°º œ……….¡.«. ….

Ò--Ò- - 5136 IV 7228-1 (¨ŠºÉ°)……………..
š¸—É ·œÂž¨Šš¸ÉÂ¥„Åžœ¸ÂÊ ¨³Âž¨Š‡ŠÁ®¨°º „µ¦‹Îµœ°Š ÓÕ
¥´Š‡Š¤¸°¥n¼˜µ¤­´µ‹µÎ œ°Š Œ´ ¨Šª´œšÉ¸ ……. ÖÔÚÔ
Á—°º œ…………. ¡.«. ….

®¤µ¥Á®˜» ­µ¦´‹—š³Á¸¥œÂž¨ŠÂ¥„ÃŒœ—šÉ¸ ÖÓÚÓ ž¨°—‹Îµœ°ŠÅ¤n˜°o Š¥„¦µ¥„µ¦‹—‹oŠÂ˜°n ¥µn ŠÄ—

˜ª´ °¥nµŠ®¤µ¥Á¨… ÓØ ˜µ¤¦³Á¸¥…o° ÓÚ (Ó)

­µ¦´‹—š³Á¥¸ œ (¦µ¥„µ¦‹—‹oŠš¸É—·œÂž¨ŠÂ¥„ŞĮ¤Ãn Œœ—šÉ¸ ÖÔÚÔ)

Áœº°Ê šÉ—¸ ·œ Áœ°Êº š—ɸ ·œ ¦³ªµŠ Á‹oµ¡œ´„Šµœš—ɸ ·œ

‹—š³Á¥¸ œ ž¦³Á£š„µ¦ Ÿo¼Ä®­o ´ µ Ÿ¼o¦´­´µ ˜µ¤­´ µ ‡ŠÁ®¨º° Á¨…š¸É—œ· ¨Š¨µ¥¤º°ºÉ°
ªœ´ Á—º°œ že ‹—š³Á¸¥œ ̜—š—¸É œ· Ä®¤n ž¦³š´˜¦µ
Ŧn Šµœ ˜µ¦µŠ Ŧn Šµœ ˜µ¦µŠ
ªµ ªµ

ª´œš…¸É ……….. ‹µÎ œ°Š œµ¥ „. œµ¥ . Ò-- - - - - (¨ŠºÉ°) œµ¥ ¡.
Á—°º œ…………. (‡¦°‹µÎ œ°Š)
Ÿ¼o¦´‹Îµœ°Š „µ¦‹Îµœ°Š¥Š´ ‡Š¤¸°¥¼˜n µ¤­´ µ‹µÎ œ°ŠŒ´¨Šª´œš…¸É .. ªœ´ š…ɸ …………….
¡.«. …………. Á—°º œ………..¡.«……
Á—°º œ………………
¡.«. ………………

(¨Š°ºÉ )…………….

˜´ª°¥nµŠ®¤µ¥Á¨… ÓÙ ˜µ¤¦³Á¥¸  …°o ÓÚ (Ó) † šÉ¸oµœ (š.—. Ò)

† š¸­É ªœ/Ŧn
† š¸Éœµ
‡µÎ …°‹—š³Á¥¸ œ­·š›·Â¨³œ˜· ·„¦¦¤ † š¸É ..............
¨³„µ¦­°­ªœ­·š›·ÄœšÉ¸—œ· ž¦³Á£š .Â.....nŠ.…...µ.¥...(.‡.…¦°……- ž…¨°…—…‹Îµœ...°..Š..).. † œ°„Á…˜
˜µÎ ®œnŠš¸—É œ· † ĜÁ…˜

¦³ªµŠ...................5..1..3..6...I.V....7..2..2..8..-.1…..........................................……..˜Îµ¨.........................................……......….....................................................…..
Á¨…šÉ¸—œ· .......................Ú...........................................………............…°ÎµÁ£°.....................................…...........................................……....................…..
®œoµ­Îµ¦ª‹...................Ó...Ù.............................................……..............‹´Š®ª—´ ...........................................................................................……........…….
̜—š—ɸ ·œ
š¸É—·œÂž¨ŠšÉ¸Â¥„Åžœ¸Ê¡oœ‹µ„„µ¦‹Îµœ°Š˜µ¤­´µ‹Îµœ°Š Œ´¨Šª´œšÉ¸……Á—º°œ………….¡.«…… Á¨…š.ɸ ...........................Ò...Ô...Ö...Ñ.........................……..........................Á¨n¤..........……Ò…Õ..………........................®œµo ......………….Ö…Ñ..…...……......…..
˜µ¤´œš¹„…o°˜„¨Šž¨°—‹Îµœ°Š ¨Šª´œšÉ¸.……..Á—º°œ………¡.«…….­nªœÂž¨Š‡ŠÁ®¨º°„µ¦‹Îµœ°Š¥´Š‡Š¤¸°¥¼n˜µ¤Á—·¤‹Îµœªœš—¸É œ· ............................Ó........…....................Ŧn.....………………- ……….....................Šµœ.................…………- …...….................…....˜µ¦µŠªµ

Á‹oµ¡œ´„Šµœš¸É—·œ Ò. …oµ¡Á‹oµŸ¼o¤¸œµ¤˜°n ޜʸ ¤¸‡ªµ¤ž¦³­Š‡r…°‹—š³Á¥¸ œ­·š›Â· ¨³œ·˜„· ¦¦¤Á„ɸ¥ª„´°­Š´ ®µ¦¤· š¦¡´ ¥šr ɸ„¨µn ª…µo Šœœ¸Ê ¨³Å—žo ’·µ–˜œÂ¨ªo
…°Ä®™o o°¥‡Îµ—oª¥‡ªµ¤­´˜¥‹r ¦Š· ™µo …µo ¡Á‹µo Ä®™o o°¥‡ÎµÅ¤Án žœ} ‡ªµ¤‹¦Š· Ä®očo™°o ¥‡Îµœ¸¥Ê œ´ …oµ¡Á‹oµÄœšµŠ‡—¸°µµÅ—o

Á¨…ž¦³‹Îµ˜ª´ ž¦³µœ

Ó. …oµ¡Á‹µo .................œ...µ..¥...„.......……..................... † †††† ††††† †† † Ÿo¼ ..…...µ.¥.....……….....….....…..

°µ¥» .............................. že ­´µ˜· .........................Å..š...¥…………............. —· µ / ¤µ¦—µºÉ° ........................................................................…......…..
† í— † ®¤µo ¥ † ‡­n¼ ¤¦­º°É .................………….......…...............…............…...........…………..
°¥nš¼ É¸ oµœ/®¤n¼µo œ ..................……....... Á¨…š¸É ........................ ˜¦°„/Ž°¥ ...........…...…................. ™œœ ..….......……..….....….....®¤n¼šÉ¸ ..…......……
˜µÎ ¨/…ªŠ .....................….............°ÎµÁ£°/Á…˜ ..............…….................. ‹Š´ ®ª—´ ..........….…...........…........®¤µ¥Á¨…Ú¦«´¡šr .............…............…

Á¨…ž¦³‹Îµ˜´ªž¦³µœ
Ô. …µo ¡Á‹µo ..................œ...µ.¥…‡…. ............................... † †††† ††††† †† † Ÿ¼o ...Ž..ºÊ°.....…............…..……..

°µ¥» .............................. že ­´ µ˜· .....…..............Å..š...¥.................... —· µ / ¤µ¦—µÉ°º ...............………............................…................…...........…..…
† í— † ®¤µo ¥ † ‡¼­n ¤¦­º°É .....................……....................­´µ˜· ………..…...…….........……
°¥š¼n ¸É oµœ/®¤n¼µo œ ................................ Á¨…š¸É .....……............ ˜¦°„/Ž°¥ ..................……............. ™œœ ................……...…..........®¤šn¼ ɸ ...…......…...

˜Îµ¨/…ªŠ ................................. °µÎ Á£°/Á…˜ ................……..................‹´Š®ª—´ ......……......….…..............®¤µ¥Á¨…Ú¦«¡´ šr ..............….......…....

Õ. …oµ¡Á‹oµ…°Â­—Š¦µ‡µš¦´¡¥šr …¸É °šµÎ œ·˜„· ¦¦¤œÁʸ žœ} ÁŠœ· .........................…….......................... µš ....…….......…............­˜µŠ‡r

Ö. …µo ¡Á‹oµ…°¦´ ¦°Šªµn

(Ò) …µo ¡Á‹µo ŤÅn —¦o ´Ã°œÂšœ®¦°º Á¡°ºÉ ž¦³Ã¥œr„n ‡» ‡¨˜nµŠ—oµª

(Ó) ¦.Å.µ.¤.‡.¤n.µ..š¸­...¦É·Š..ž´¡..¨¥...šr¼„..­Âɸ...­¦..µo—..Š.Š.Å...ª..Äo ..œ...Õ......Á..ž..œ}...¦..µ..‡..µ..š...¸ÂÉ ..š..…‹o ¦…·Š ….........................................................................................…...................……
(Ô)
(Õ) .Ÿ..…o¼...µ.¥..Å...—..oš...ɗ¸ ..œ·...¤..µ..Ã..—...¥..…....…....…....…....…....Á.ž...}œ..Á.ª..¨...µ..…....…....…...…že Å…¤…‡n µo .Š....ε..¦..³..£...µ..¬..¸...µÎ..¦..»Š..š...o°..Š..š...¸É ............................................…...............……
(Ö) .Ÿ..…o¼...µ.¥..Å..—...¦o..´.....ε..¦..³..¦..µ..‡..µ..š...ɸ—..·œ...‡..¦.....™...oª..œ...Â..¨..ªo................………....................................................................…..........…...............……
....................ª....œ´......š.......¸É ..................œœ.........µµ......¥¥.........„‡...............Á..—....°º......œ...............................................ŸŸ..…¼oo¼…..°°....…Ž..µº°Ê..¥....…........ ¡.«.
...........…….......

¨ŠºÉ°
¨Šº°É
¨ŠºÉ° ........................................................... Ÿ­o¼ °­ªœ

(………………………………………)

­µÎ ®¦´¡œ„´ ŠµœÁ‹µo ®œµo š¸É

Ò) ¦µ‡µž¦³Á¤·œšœ» š¦¡´ ¥.r .......................................………........……………...................………….µš..........…….…….............…..............­˜µŠ‡r
Ó) ̜—šÉ—¸ ·œÄ®¤¦n ³ªµŠ............5..3..1..6.…IV…7.2..2..8..-..1...........Á¨…š¸É—œ· ..........…....…Ò…Ñ…….......……..........®œµo ­µÎ ¦ª‹....................…Ó…Ú ………...............

̜—š—¸É œ· Á¨…š.¸É .......................Ò…Ô…ÖÒ................….....Á¨n¤.................………Ò…Õ.......................……..®œµo …………………..…Ö…Ò….………………
‹‡ÎµŠœÁ®ª¨œ°º š..¸É—..œ·...........................................….....................ÒÒ.….……………...........….…............ÅŦ¦n.n.........................…..………...............….………--………………..............................….....ŠŠµµœœ...................…....….…..…...........……....…--.........…..........................˜˜µµ¦¦µµŠŠªªµµ
Ô) ŗ‹o —š³Á¥¸ œÂ¨oªÂ˜nª´œš.¸É ..............…...............Á—º°œ...............................¡.«. ……………….

¨Š°Éº ..................................................................
( ................................................................. )
Á‹µo ¡œ„´ Šµœš—ɸ ·œ

˜ª´ °¥nµŠ®¤µ¥Á¨… ÓÙ ˜µ¤¦³Á¥¸  …°o ÓÚ (Ó) (š.—. Ò×)

´œš„¹ …o°˜„¨Šž¨°—‹µÎ œ°Š

šÉ—¸ œ·
¦³ªµŠ.......…5…13…6IV…7…22…8-1..........................…..˜Îµ¨...........……………………………..…………….............
Á¨…š—¸É œ· …………Ú…………®œoµ­Îµ¦ª‹......………Ó....Ù...........°ÎµÁ£°..............…........……................................
̜—®¤µ¥Á¨…š…ɸ ……ÒÔ…Ö…Ñ………………….……….‹Š´ ®ª´—................................…….…...........................
š¸Éªµn „µ¦…………..….…………………………
ª´œš…ɸ ………Á—º°œ………….…….…¡.«. ……………

Á¨…ž¦³‹µÎ ˜ª´ ž¦³µœ

…oµ¡Á‹oµ ..……….....œ...µ.¥...….......…Ÿ…o¼¦´…‹.ε..œ…°.Š........................………....... † †††† ††††† †† †
..……….....œ..µ..¥...„.......…Ÿ…‹o¼ µÎ…œ.°..Š….........................………....... † †††† ††††† †† †

°µ¥» ................ že Áº°Ê µ˜…· ………….…… ­´µ˜·........................... ·—µ / ¤µ¦—µº°É ..........….….........................................
°¥nš¼ ɸµo œ/®¤¼noµœ ...................... Á¨…š¸É ................. ˜¦°„/Ž°¥ ....…….........….......... ™œœ ..........…….…………..®¤nš¼ ¸É .....…...
˜Îµ¨/…ªŠ ...................... °µÎ Á£°/Á…˜ ............................ ‹Š´ ®ª´— ...…......………................®¤µ¥Á¨…Ú¦«¡´ šr .….....................
…///°//ž//’///· //µ//–///˜//œ///Â//¨//³//Ä/®///™o//o°//¥//‡//ε//˜//°n …ŗ…oš…µÎ …´œš…¹„……°o …˜„…¨…Š˜…°n Á…‹oµ…¡œ…´„…Šµœ…š…—ɸ œ·………………………………………………………..
—///ªo //¥/‡///ª//µ/¤//­///˜´ //¥//‹r //¦//Š· —´Š˜n°ÅžœÊ¸ : -
…………š…¸É—…·œÂ…ž…¨Š…Á‡…¦Éº°…Š®…¤…µ¥……oµ…Š…œ…œÊ¸……oµ…¡…Á‹oµ…œ.…µ¥…„…. Ÿ…o¼‹Îµ…œ°…ŠÅ.…—o‹…圅°…ŠÅ…ªo„…´…œ…µ¥………. Ÿ…o¼¦´…‹…εœ..°…Š…×…¥Å…—o‹…µÎ œ…°…Š˜…µ¤….
…­´……µ‹…圅°…Š¨…Šª…´œš……¸É …………….Á…—º°.œ……………..………………………¡.…«…………..……….Á¡…ɺ°…Áž}œ…ž…¦³…„´œ.…®…œ¸Ê„…¼¥o ¤º…ÁŠ…·œ…ŽŠÉ¹ …Ÿ¼o‹…圅°…Š„.¥o¼.…º¤Å…ž‹…µ„…Ÿ…¦o¼ ´ …‹µÎ…œ°…Š.
…Ážœ}…‹…圅ªœ……………………….…………………µš…(…………………..………………….…...…….…………) …—´ .…œÊ¸ œ…µ…¥ „…. Å…—…Âo …nŠ……µ¥…š…—¸É ·œ…ž…¨…Šœ..¸ÊÄ…®…o„…n œ…µ¥…‡.…×…¥…šÉ¸—…œ· .
…­nª…œÂ……nŠÂ…¥„…Ş…Áž…œ} …Ì…œ…—š…—¸É œ·…Ä.®…¤…Án ¨……š……¸É …………Ò…Ô…Ö……Ò…………………..……oµ¡…Á‹…oµš…´ÊŠ­…°…Š .…iµ¥…˜„…¨Š…„´œ…Ä…®oš…¸É—…·œÃ…Œ…œ—..š…¸É—…·œÂ…ž…¨Š…Â¥…„…Ä®…¤n.
…Á¨……š…¸É………Ò…Ô…Ö……Ò……………..¡…oœ…‹µ…„„…µ¦…‹µÎ…œ…°Š…Ş…Ã…—¥…š…¸É¥´Š.¤…·Å—…o¤…¸„µ…¦…µÎ ¦…³®.…œ…ʸšÉ¸‹…µÎ œ…°…ŠÁž…}œ…ž¦…³…„´œ…˜…n°…¥µn …ŠÄ.—.…­…ªn œ…Ì…œ…—š…—¸É …œ· Â…ž…¨Š.
…‡Š…Á®…¨º°…¥´Š…‡…Š‹…µÎ œ…°Š…Áž…}œ…ž¦…³„…´œ.…®œ…ʸąœª…ŠÁ…Š·œ…Á—…·¤°…¥…n¼˜µ…¤Á…—·¤…ÁŠ…ºÉ°…œÅ……Â…¨…³……o°.˜…„…¨Š…°Éºœ…Ç…Ä…®…oÁž…}œÅ…ž…˜µ.¤.…­…´…µ…‹Îµ…œ°…ŠÁ…—·¤….
…š„» …ž¦…³…„µ…¦ ………………………………………….……………….…………………………………..……………………….
……………´œ…š¹„………o°˜…„…¨Š…œ¸Êš…µÎ Å…ª.o®…œ…ɹŠŒ……´ …Á„ȝ…Å…ªo –……­µÎ …œ´„…Šµ…œ…šÉ¸—…·œ…š…´ÊŠ­…°Š… iµ.…¥Å…—o˜…¦ª…‹…—¼…´œ…š¹„……o°…˜…„¨..Š…Â…¨³…Á……oµÄ…‹……o°‡…ª…µ¤.
…˜¨…°—…Â…¨oª…‹¹Š…¨…Š¨…µ¥…¤°º …°ºÉ…®…¦°º …¨Š…¨…µ¥¡…·¤…¡…rœ·Êª…¤°º…Å…ªÁo ž.…œ} ®…¨…´„“…µœ…˜…°n ®.…œoµ…¡…¥µœ…Â…¨³…Á‹…oµ¡…œ…„´ Š…µœ…šÉ¸—…·œ…..……………………….

………………………………….……………………………………………….…………………………..…………………….

……………………………………………………….……………….…………………………………..……………………….
………………………………….……………………………¨Š…ºÉ°……………………………œ…µ.…¥…………. ………………………Ÿo¦¼ …´ ‹…µÎ œ…°.Š.…………………….
……………………………………………………….………¨Š…ºÉ°………….…………………œ…µ…¥…„……. ………………………Ÿ‹o¼ …圅°.Š.……………………….
………………………………….……………………………¨Š…°Éº ……………………………….…………………………………¡¥…µœ……..…………………….
……………………………………………………….………¨Š…°ºÉ ………….………………………………………………………¡¥…µœ…..……………………….
……………´œ…š„¹………°o ˜…„¨…Š…œÅ¸Ê …—šo…ε˜.…n°®…œ…oµ ……………………………………….…………………………..…………………….
……………………………………………………….………¨Š…Éº°………….………………………………………………………Á‹oµ…¡…œ´„..Š…µœ…š…—ɸ œ· ……………….
……………………………………………………….……………ž…¦³.š…´…˜¦…µ˜…ε…®…œnŠ…Áž…}œ­…µÎ …‡´ ………..……………………….

………………………………….……………………………………………….…………………………..…………………….

……………………………………………………….……………….…………………………………..……………………….

………………………………….……………………………………………….…………………………..…………………….

˜´ª°¥µn Š®¤µ¥Á¨… ÓÙ ˜µ¤¦³Á¸¥…°o ÓÚ (Ó)

­µ¦´‹—š³Á¥¸ œ

(¦µ¥„µ¦‹—š³Á¸¥œÂž¨ŠÁ—¤· ̜—š¸É ÒÔÖÑ)

Áœ°ºÊ š—ɸ œ· ÁœÊº°š—¸É œ· ¦³ªµŠ Á‹µo ¡œ´„Šµœš—¸É ·œ
Á¨…š—¸É ·œ ¨Š¨µ¥¤º°ºÉ°
‹—š³Á¥¸ œ ž¦³Á£š„µ¦ ŸÄo¼ ®o­´ µ Ÿ¼¦o ´­´ µ ˜µ¤­´µ ‡ŠÁ®¨º°
ªœ´ Á—°º œ že ‹—š³Á¸¥œ ̜—š¸É—œ· Ä®¤n ž¦³š´ ˜¦µ
œµ¥ …. Ŧn Šµœ ˜µ¦µŠ Ŧn Šµœ ˜µ¦µŠ
Ÿo¦¼ ´ ‹µÎ œ°Š ªµ ªµ

ªœ´ šÉ¸…………. ‹Îµœ°Š œµ¥ „. Ó- - --- - (¨ŠºÉ°) œµ¥ ¡.
Á—º°œ…………
¡.«. …………

ª´œš¸É…………. Šn …µ¥ œµ¥ „. œµ¥ ‡. Ò - - Ò - - 5316 IV 7228-1 (¨ŠÉº°)…………

Á—°º œ………… (‡¦° - ž¨°—‹Îµœ°Š) š¸É—·œÂž¨ŠšÉ¸Â¥„Åžœ¡¸Ê oœ‹µ„„µ¦‹µÎ œ°Š˜µ¤­´ µ ÒÑ
‹µÎ œ°Š Œ´ ¨Šª´œš…ɸ …..Á—º°œ…………¡.«……. ÒÔÖÒ
¡.«. …………

˜µ¤œ´ š¹„…o°˜„¨Šž¨°—‹Îµœ°Š ¨Šª´œš…¸É ….

Á—º°œ…………¡.«…..­nªœÂž¨Š‡ŠÁ®¨°º „µ¦‹Îµœ°Š

¥´Š‡Š¤¸˜µ¤Á—·¤

®¤µ¥Á®˜» ­µ¦´ ‹—š³Á¥¸ œÂž¨ŠÂ¥„ÃŒœ—š¸É ÒÔÖÒ ž¨°—‹Îµœ°Š Ťn˜o°Š¥„¦µ¥„µ¦‹—‹oŠÂ˜n°¥nµŠÄ—

˜ª´ °¥nµŠ®¤µ¥Á¨… ÓÚ ˜µ¤¦³Á¥¸ …°o ÓÚ (Ô) † šÉ¸ oµœ (š.—. Ò)

„¦–¸­ªn œ…°ŠŸ¼o‹µÎ œ°ŠÁž}œÂž¨ŠÂ‡¨Š³Á®„¨µ¦º°­°­ª‡œÎµ…­°·š‹›—·Äœšš³Áɗ¸ œ· ¸¥œž­¦š·³Á›£Â· š¨³...œ..˜·.Â..·„..¦.nŠ.¦„..¤.¦.…¦¤…­·š…›¦Í·…ª¤……...††††......šššœ­Éœ¸¸¸ÉÉ°..„ªµ..œÁ.…../.˜Å..¦..n..
˜ÎµÂ®œnŠš—¸É œ· (‡¦° - ž¨°—‹Îµœ°Š) † ĜÁ…˜ Â¥„ Ò

¦³ªµŠ..................5..1..3..6...I.V....7..2..2..8..-..1…..........................................……..˜Îµ¨.........................................……......….....................................................…..
Á¨…š¸É—œ· .......................Ú...........................................………............…°ÎµÁ£°.....................................…...........................................……....................…..
®œµo ­Îµ¦ª‹...................Ò..Ú..............................................……..............‹´Š®ª—´ ...........................................................................................……........…….
̜—š¸—É ·œ

Á¨…š.¸É ...............Ò...Ó...Ô...Ñ.....................................……..........................Á¨¤n ..........……Ò…Ô..………........................®œoµ......………….Ô…Ñ..…...……......…..

‹µÎ œªœš—¸É œ· ....................................Ó…....................Ŧn.....………………- ……….....................Šµœ.................…………- …...….................…....˜µ¦µŠªµ

šÉ¸—·œÂž¨ŠšÉ¸Â¥„ÅžœÊ¸¡oœ‹µ„„µ¦‹Îµœ°Š˜µ¤­´µ‹Îµœ°ŠÁŒ¡µ³­nªœŒ´¨Šª´œš¸É……Á—º°œ………..¡.«…… Ò. …oµ¡Á‹oµŸ¼o¤œ¸ µ¤˜°n ޜʸ ¤‡¸ ªµ¤ž¦³­Š‡r…°‹—š³Á¸¥œ­·š›Â· ¨³œ˜· ·„¦¦¤Á„¥É¸ ª„´ °­Š´ ®µ¦¤· š¦¡´ ¥šr ɸ„¨nµª…oµŠœœÊ¸ ¨³Å—žo ’·µ–˜œÂ¨ªo
˜µ¤´œš¹„…o°˜„¨Šž¨°—‹Îµœ°Š ¨Šª´œš¸É…..Á—º°œ……..¡.«…… …°Ä®™o °o ¥‡µÎ —oª¥‡ªµ¤­´˜¥‹r ¦·Š ™µo …µo ¡Á‹oµÄ®™o o°¥‡ÎµÅ¤Án žœ} ‡ªµ¤‹¦·ŠÄ®Äo o™°o ¥‡ÎµœÊ¥¸ ´œ…oµ¡Á‹oµÄœšµŠ‡—¸°µµÅ—o
Á¨…ž¦³‹Îµ˜´ªž¦³µœ
Á‹oµ¡œ´„ŠµœšÉ¸—·œ Ó. …oµ¡Á‹oµ ..................Ò.....œ...µ..¥...„...……..................... † †† † Ÿo¼ ........™...°º …„¦…¦…¤­..·š...›…Í· .....…..
Ó. œµŠ …. †††† †††††

°µ¥» .......Ö....Ñ..,.Õ...Ö............. že ­´µ˜· .............Å..š...¥............…………............. ·—µ / ¤µ¦—µºÉ° ........................................................................…......…..
† í— † ®¤µo ¥ † ‡­n¼ ¤¦­°Éº .................………….......…...………...........…............…...........……
°¥n¼šÉ¸ oµœ/®¤¼noµœ ..................……....... Á¨…š¸É ........................ ˜¦°„/Ž°¥ ...........…...…................. ™œœ ..….......……..….....….....®¤š¼n ¸É ..…......……
˜Îµ¨/…ªŠ .....................….............°ÎµÁ£°/Á…˜ ..............…….................. ‹´Š®ª´— ..........….…...........…........®¤µ¥Á¨…Ú¦«´¡šr .............…............…

Á¨…ž¦³‹µÎ ˜´ªž¦³µœ

Ô. …oµ¡Á‹oµ ..................œ...µ.Š………. ............................... † †††† ††††† †† † Ÿo¼ ........™..º°…„.¦..¦..¤...­..·š..…›Í· ..……..

°µ¥» ............Õ...Ö............... že ­´ µ˜· .....….....Å..š...¥............................. ·—µ / ¤µ¦—µº°É ...............………............................…................…...........…..…
† í— † ®¤µo ¥ † ‡­¼n ¤¦­É°º .....................……....................­´ µ˜· ………..…...…….........……
°¥n¼šÉ¸ µo œ/®¤¼n oµœ ................................ Á¨…š¸É .....……............ ˜¦°„/Ž°¥ ..................……............. ™œœ ................……...…..........®¤¼šn ɸ ...…......…...

˜µÎ ¨/…ªŠ ................................. °ÎµÁ£°/Á…˜ ................……..................‹´Š®ª´— ......……......….…..............®¤µ¥Á¨…Ú¦«¡´ šr ..............….......…....
Õ. …µo ¡Á‹oµ…°Â­—Š¦µ‡µš¦¡´ ¥ršÉ¸…°šµÎ œ˜· „· ¦¦¤œÊÁ¸ ž}œÁŠœ· .........................……...-....................... µš ....…….......…............­˜µŠ‡r

Ö. …oµ¡Á‹oµ…°¦´¦°Šªnµ

(Ò) …µo ¡Á‹oµÅ¤Ån —¦o ´Ã°œÂšœ®¦º°Á¡º°É ž¦³Ã¥œr„n ‡» ‡¨˜µn Š—oµª

(Ó) ¦.Â.µ..‡..nŠµ..„š..¦.¦.¦.´¡.¤.¥..­.rš.·š.ɸÂ..›.­..Í·¦—..ª.Š.¤Å...ª˜..Äo .µ.œ¤...‡Õ..ε...….Á..ž°..Œ}œ...¦..µ´..‡.¨.µ.Š.š.ª..Âɸ ´œ..š.š.…o‹…¸É ¦…·Š……Á—.°º...œ...…....…....…....¡....«...…....…............................................................…...................……
(Ô)
(Õ) ..............................................................................……….................................................................................…...............……
(Ö) ..............................................................................………....................................................................…..........…...............……
ª´œš.ɸ ................. Á—°º œ ...............................…........ ¡.«. ...........…….......
¨ŠÉº° .......................œ...µ..¥...„............................. Ÿ¼o…°™º°„¦¦¤­·š›Í·
¨ŠºÉ° .......................œ...µ..Š...…............................ Ÿ¼…o °™º°„¦¦¤­š· ›·Í
¨Š°Éº ........................................................... Ÿ­o¼ °­ªœ

(………………………………………)

­Îµ®¦´¡œ´„ŠµœÁ‹µo ®œoµš¸É

Ò) ¦µ‡µž¦³Á¤·œšœ» š¦´¡¥.r .......................................………........……………...................………….µš..........…….…….............…..............­˜µŠ‡r
Ó) ̜—šÉ—¸ œ· Ä®¤¦n ³ªµŠ..............5..1..3.…6 I…V.7..2..2..8..-..1.........Á¨…š—¸É œ· ..........…....……Ò…Ñ….......……..........®œµo ­Îµ¦ª‹....................…Ó…Ñ ………...............

̜—šÉ—¸ œ· Á¨…š.¸É .......................Ò…Ó…Ô.Ò...............….....Á¨¤n .................…………Ò...Ô....................……..®œµo …………………..…ÔÒ…….………………

‹µÎ œªœš—ɸ ·œ....................….........…Ò……......….......Ŧn...............……......……-………....................Šµœ...............……....…..-......…...........˜µ¦µŠªµ
‡ŠÁ®¨°º .........................................…Ò ……......….....Ŧn.............……..........……- ………..............….Šµœ.........…….........…..…- ..................˜µ¦µŠªµ

Ô) ŗ‹o —š³Á¸¥œÂ¨ªo ˜ªn ´œš.¸É ..............…...............Á—º°œ...............................¡.«. ……………….
¨Š°Éº ....................................................................
( ................................................................ )
Á‹µo ¡œ´„Šµœš—¸É œ·

˜ª´ °¥nµŠ®¤µ¥Á¨… ÓÚ ˜µ¤¦³Á¥¸ …°o ÓÚ (Ô) † šÉ¸ oµœ (š.—. Ò)

† š¸­É ªœ/Ŧn
¨³„µ¦­°­ª‡œÎµ…­°š· ‹›—Ä· œšš³Áɸ—œ· ¸¥œž­¦·š³Á›£·Âš¨³...œ..˜·.Â..·„..¦.nŠ.¦„..¤.¦.…¦¤…­š· …›·¦Í…ª¤……..†††......ššœ. œÉ¸É¸°..„µ..Á.…...˜......
˜µÎ ®œnŠšÉ—¸ ·œ
(‡¦° - ž¨°—‹Îµœ°Š) † ĜÁ…˜ ž¨Š‡ŠÁ®¨°º

¦³ªµŠ...........................5..1..3..6...I.V....7.…22.8..-.1......................................……..˜Îµ¨.........................................……......….....................................................…..
Á¨…šÉ¸—·œ..............................Ú....................................………............…°ÎµÁ£°.....................................…...........................................……....................…..
®œoµ­µÎ ¦ª‹........................Ò..Ú.........................................……..............‹Š´ ®ª—´ ...........................................................................................……........…….
̜—šÉ¸—·œ
Á¨…š.¸É ...........................Ò...Ó...Ô...Ñ.........................……..........................Á¨¤n ..........……Ò…Ô..………........................®œµo ......………….Ô…Ñ..…...……......…..
šÉ¸—·œÂž¨Š‡ŠÁ®¨º°„µ¦‹Îµœ°Š¥´Š‡Š¤¸°¥¼n˜µ¤­´µ‹Îµœ°ŠÁŒ¡µ³­nªœ Œ´¨Šª´œš¸É…..Á—º°œ……….¡.«……
Á‹oµ¡œ´„Šµœš¸É—·œ ‹ÎµœªœšÉ¸—·œ.....................Ò...............…....................Ŧn.....………………- ……….....................Šµœ.................…………- …...….................…....˜µ¦µŠªµ

Ò. …µo ¡Á‹µo Ÿo¼¤¸œµ¤˜°n Şœ¸Ê ¤‡¸ ªµ¤ž¦³­Š‡…r °‹—š³Á¸¥œ­š· ›Â· ¨³œ·˜·„¦¦¤Á„¥¸É ª„´ °­´Š®µ¦·¤š¦´¡¥rš¸„É ¨µn ª…oµŠœœ¸Ê ¨³Å—žo ’·µ–˜œÂ¨oª
…°Ä®o™o°¥‡Îµ—ªo ¥‡ªµ¤­˜´ ¥r‹¦·Š ™µo …oµ¡Á‹oµÄ®o™°o ¥‡ÎµÅ¤Án ž}œ‡ªµ¤‹¦Š· Ä®očo™°o ¥‡Îµœ¸Ê¥œ´ …µo ¡Á‹oµÄœšµŠ‡—¸°µµÅ—o
Á¨…ž¦³‹µÎ ˜´ªž¦³µœ
Ó. …µo ¡Á‹µo ..................ÒÓ.......œœ...µµ..¥Š..….„.….. …..................... † †† † Ÿ¼o ........™...º°…„¦…¦…¤­..·š...›…·Í .....…..
†††† †††††

°µ¥» ............Ö...Ñ..,.Õ...Ö......... že ­´ µ˜· .............Å..š...¥............…………............. ·—µ / ¤µ¦—µºÉ° ........................................................................…......…..
† í— † ®¤µo ¥ † ‡­¼n ¤¦­ºÉ° .................………….......…...………...........…............…...........……
°¥š¼n ɝ¸ oµœ/®¤¼n µo œ ..................……....... Á¨…šÉ¸ ........................ ˜¦°„/Ž°¥ ...........…...…................. ™œœ ..….......……..….....….....®¤¼šn ɸ ..…......……
˜Îµ¨/…ªŠ .....................….............°ÎµÁ£°/Á…˜ ..............…….................. ‹´Š®ª´— ..........….…...........…........®¤µ¥Á¨…Ú¦«´¡šr .............…............…

Á¨…ž¦³‹µÎ ˜ª´ ž¦³µœ
Ô. …oµ¡Á‹µo ..................œ...µ.¥…„…. ............................... † †††† ††††† †† † Ÿo¼ ........™..°º…„.¦..¦..¤...­..·š..…›Í· ..……..

°µ¥» ............Ö...Ñ............... že ­´ µ˜· .....….....Å..š...¥............................. —· µ / ¤µ¦—µÉº° ...............………............................…................…...........…..…
† í— † ®¤µo ¥ † ‡n­¼ ¤¦­º°É .....................……....................­´ µ˜· ………..…...…….........……
°¥n¼šÉ¸µo œ/®¤¼noµœ ................................ Á¨…š¸É .....……............ ˜¦°„/Ž°¥ ..................……............. ™œœ ................……...…..........®¤š¼n ɸ ...…......…...

˜Îµ¨/…ªŠ ................................. °ÎµÁ£°/Á…˜ ................……..................‹´Š®ª´— ......……......….…..............®¤µ¥Á¨…Ú¦«´¡šr ..............….......…....

Õ. …oµ¡Á‹oµ…°Â­—Š¦µ‡µš¦¡´ ¥rš¸É…°šµÎ œ·˜·„¦¦¤œÁʸ ž}œÁŠœ· .........................…….......................... µš ....…….......…............­˜µŠ‡r

Ö. …oµ¡Á‹µo …°¦´ ¦°Šªµn

(Ò) …oµ¡Á‹µo ŤÅn —¦o ´ ðœÂšœ®¦°º Á¡°ºÉ ž¦³Ã¥œÂr „n ‡» ‡¨˜µn Š—µo ª

(Ó) ¦.Â.µ..‡..nŠµ..„š..¦.¦.¦.¡´ .¤.¥..­.šr .·š.¸É..›.­..·Í¦—..ª.Š.¤Å...ª˜..Äo .µ.œ¤...‡Õ..µÎ...….Á..ž°..Œ}œ...¦..µ´..‡.¨.µ.Š.š.ª..Â¸É œ´..š.š.…o‹…ɸ ¦…Š· ..Á…—º°..œ...…....…....…....…....¡....«......….............................................................…...................……
(Ô)
(Õ) ..............................................................................……….................................................................................…...............……
(Ö) ..............................................................................………....................................................................…..........…...............……
ª´œš.ɸ ................. Á—º°œ ...............................…........ ¡.«. ...........…….......
¨ŠÉº° ......................œ...µ..Š...…............................. Ÿo¼…°Ÿ¼™o º°„¦¦¤­·š›Í·
¨Š°Éº ......................œ...µ..Š...„.............................. Ÿo…¼ °Ÿo™¼ º°„¦¦¤­·š›Í·
¨Š°Éº ........................................................... Ÿ¼­o °­ªœ

(………………………………………)

­µÎ ®¦´ ¡œ„´ ŠµœÁ‹oµ®œoµšÉ¸

Ò) ¦µ‡µž¦³Á¤œ· šœ» š¦¡´ ¥.r .......................................………........……………...................………….µš..........…….…….............…..............­˜µŠ‡r

Ó) ̜—šÉ¸—·œÄ®¤n¦³ªµŠ...................……-....................Á¨…š¸É—œ· ..........…....……-…….......……..........®œµo ­Îµ¦ª‹....................…- …………...............
̜—š—ɸ ·œÁ¨…š.ɸ .......................……....-............….....Á¨¤n .................…………-.......................……..®œoµ…………………..…-…….………………
‹Îµœªœš¸É—·œ....................….........………- ......….......Ŧn...............……......……-………....................Šµœ...............……....…..-......…...........˜µ¦µŠªµ
‡ŠÁ®¨°º .........................................……-…......….....Ŧn.............……..........……- ………..............….Šµœ.........…….........…..…- ..................˜µ¦µŠªµ

Ô) ŗ‹o —š³Á¸¥œÂ¨ªo ˜ªn ´œš.¸É ..............…...............Á—º°œ...............................¡.«. ……………….
¨Š°Éº ....................................................................
( ................................................................ )
Á‹oµ¡œ„´ ŠµœšÉ—¸ œ·

˜´ª°¥µn Š®¤µ¥Á¨… ÓÚ ˜µ¤¦³Á¸¥…°o ÓÚ (Ô) (š.—. Ò×)

œ´ š„¹ …o°˜„¨ŠÁ¦É°º Šž¨°—‹µÎ œ°Š

šÉ¸—œ·
¦³ªµŠ.......…5…13…6 I…V7…22…8-.1.........................…..˜Îµ¨...........……………………………..…………….............
Á¨…š¸É—œ· ………Ú……………®œµo ­µÎ ¦ª‹......………ÒÚ...............°µÎ Á£°..............…........……................................
̜—®¤µ¥Á¨…š…ɸ ……………Ò…Ó…ÔÑ………….……….‹´Š®ª´—................................…….…...........................
šÉ¸ªµn „µ¦…………..….…………………………
ªœ´ š…¸É ………Á—º°œ………….…….…¡.«. ……………

Á¨…ž¦³‹µÎ ˜ª´ ž¦³µœ

…oµ¡Á‹oµ ..……….....œ...µ.¥..........…Ÿ…o¼¦´ …‹Îµ..œ.…°Š.........................………....... † †††† ††††† †† †
..……….....œ..µ..¥...„........…Ÿ…o‹¼ 兜°..Š.….........................………....... † †††† ††††† †† †

°µ¥» ...Ö...Ñ...,.Õ...Ö... že Áº°Ê µ˜…· …Ś…¥…….…… ­´µ˜·.......Å..š...¥............... ·—µ / ¤µ¦—µº°É ..........….….........................................
°¥šn¼ É¸ µo œ/®¤¼n µo œ ...................... Á¨…šÉ¸ ................. ˜¦°„/Ž°¥ ....…….........….......... ™œœ ..........…….…………..®¤¼nšÉ¸ .....…...
˜µÎ ¨/…ªŠ ...................... °ÎµÁ£°/Á…˜ ............................ ‹´Š®ª´— ...…......………................®¤µ¥Á¨…Ú¦«¡´ šr .….....................
/…//°//ž//’///·//µ//–///˜//œ///Â//¨//³//Ä/®///™o//°o//¥//‡//ε//˜//n°…ŗ…ošÎµ…œ´…š…¹„……o°…˜„…¨Š…˜n°…Á‹…oµ¡…œ…´„Š…µœ…š…—ɸ œ· ………………………………………………………..
—///oª//¥/‡///ª//µ/¤//­///˜´ //¥//‹r //¦//Š· —´Š˜°n Şœ¸Ê : -
………………o°…Ò…. ˜…µ¤…š…¸É…oµ…¡Á…‹oµ…š´ÊŠ…­°…Š …iµ¥…ŗ…o‹…—š…³Á…¸¥.…œ‹…圅°…ŠÁŒ…¡…µ³­.…nªœ…š…¸É—·œ…Â…ž¨…ŠÁ…‡¦…º°É Š…®…¤µ…¥……oµŠ…œ..…œ¸ÊÅ…ªo˜…n°…„´œ…˜…µ¤…­…´…µ.
‹…µÎ œ…°…ŠÁ…Œ¡…µ³…­…ªn œ…Œ…´ …¨Š…ª´œ…š…¸É….…..Á—…°º œ…………….…………¡….«………………´—œ…ʸ Ÿ…o¼™°º…„…¦¦…¤­…·š.›…·ÄÍ œ…š…—ɸ œ·…Â…ž¨…Šœ…ʸŅ—o……°¦…´Šª..—´…Â…nŠ…„¦…¦¤…­…š· ›…·Í¦…ª¤.
…¨…³Á¦…ºÉ°…ŠÂ…nŠ…Â¥…„Á…­¦…ȋÁ…¦¸¥…¦…o°¥…¡…¦°o …¤š…ɸ‹…³‹…—š…³Á…¸¥…œ.Â…¨oª………µo ¡…Á‹…oµ œ…µ.¥……. Ÿ…¼¦o ´ …‹Îµ…œ…°Š…¥·œ…¥…°¤…Ä®…o‹…—š…³Á..…¸¥œ…Â…nŠ…„¦…¦¤…­…·š›…¦Í· ª…¤.
…×…¥Ä…®šo …—¸É …œ· Ã…Œœ…—…šÉ¸—…·œ…Á¨……š…¸É Ò…Ó.Ô…Ò…Ž…¹ÉŠÁ…ž}œ………°Š…œµ…Š …….…¡oœ…‹…µ„…„µ…¦‹…圅°…Š ‡…Š¤.…„¸ µ…¦‹…圅°…Š‡…¦°……˜—· …°¥…n¼ÁŒ.¡.…µ³…š…ɸ—·œ…Ì…œ…—š…¸É—…œ· .
…Á¨……š…¸É Ò…Ó…ÔÑ…Ž…¹ÉŠ…Áž…}œ……°Š…œ…µ¥…„.…˜…µ¤…­´ ……µ‹…圅°…ŠÁŒ.…¡µ…³­…nª…œ …Œ…´.¨…Šª…´œ…š…ɸ ….….Á—…º°œ…………………¡….«………….Å.…ž˜…µ¤…Á—…·¤…………….
………………o°…Ó…. ……oµ¡…Á‹…oµš…Ê´Š­…°…Š .…iµ¥˜…„…¨Š…¥·œ…¥°…¤…„´œ…Ä®…oÁ‹…oµ¡…œ…´„Š…µœ…š¸—É…·œ…‹—…š…³Á.…¸¥œ…Ä®…o……oµ¡…Á‹…oµ˜…µ¤…‡ª…µ¤…ž.¦.…³­…Š‡…—r ´Š…„¨…nµª………oµŠ˜…oœ.
……………´œ…š¹„………o°˜…„…¨Š…œÊ¸š…εŅª…o ®…œÉ¹Š…Œ…´…Á„…ȝ…Ū…o –.…­Îµ…œ…´„Š…µœ…š…ɸ—·œ.…š…´ÊŠ­…°Š… iµ…¥Å…—…o˜¦…ª‹…—¼…œ´ …š¹„………°o ˜..„…¨…ŠÂ…¨³…Á……oµÄ‹………o°‡…ªµ…¤.
…˜¨…°—…Â…¨oª…‹…¹Š¨…Š¨…µ¥…¤º°……ɺ°Å…ªoÁ…ž}œ.…®¨…´„…“µ…œ˜…n°…®œ…µo ¡…¥…µœ…¨…³Á…‹µo …¡œ…´„…Šµ…œš…¸É—…·œ .…………………………..…………………….

……………………………………………………….……………….…………………………………..……………………….
………………………………….…………………¨Š…ºÉ°…………………………………œ…µ…¥……….…….……………………….Ÿ…¦¼o ´ …‹µÎ …œ°…Š…..…………………….
……………………………………………………¨…Š.ºÉ°……………………………….…œ…µ…¥…„……. …………………………….Ÿ…o¼‹Îµ…œ°…Š …..……………………….
………………………………….…………………¨Š…°Éº …………………………………………………….……………………….¡…¥µ…œ ………..…………………….
……………………………………………………¨…Š.ºÉ°……………………………….…………………………………………….¡…¥µ…œ ……..……………………….

………………………………….……………………………………………….…………………………..…………………….
……………´œ…š¹„………o°˜…„¨…Š…œÅʸ …—oš…µÎ ˜…°n …®œ…oµ…………….……………….…………………………………..……………………….
………………………………….…………………¨Š…°ºÉ…………………………………………………….………………………Á‹…oµ¡…œ´„…Šµ…œ…š—¸É ..œ·…………………….
……………………………………………………….……ž…¦³…š´…˜…¦µ.˜…ε…®…œnŠ…Áž…}œ…­µÎ …‡´………………..……………………….

……………………………………………………….……………….…………………………………..……………………….

………………………………….……………………………………………….…………………………..…………………….

……………………………………………………….……………….…………………………………..……………………….

………………………………….……………………………………………….…………………………..…………………….

˜ª´ °¥µn Š®¤µ¥Á¨… ÓÚ ˜µ¤¦³Á¥¸ …o° ÓÚ (Ô) (¦µ¥„µ¦‹—š³Á¥¸ œ ž¨ŠÁ—·¤ ̜—šÉ¸ ÒÓÔÑ)
­µ¦´ ‹—š³Á¥¸ œ

ÁœÊº°š¸É—œ· ÁœÊº°š—ɸ œ· ¦³ªµŠ Á‹µo ¡œ´„Šµœš¸É—·œ
Á¨…š—ɸ œ· ¨Š¨µ¥¤º°°Éº
‹—š³Á¥¸ œ ž¦³Á£š„µ¦ ŸÄo¼ ®­o ´µ Ÿ¼o¦´ ­´ µ ˜µ¤­´µ ‡ŠÁ®¨º°
ª´œ Á—º°œ že ‹—š³Á¥¸ œ ̜—š—¸É œ· Ä®¤n ž¦³š´˜¦µ
œµ¥ . Ŧn Šµœ ˜µ¦µŠ Ŧn Šµœ ˜µ¦µŠ
Ÿo¦¼ ´ ‹Îµœ°Š ªµ ªµ

ªœ´ š…¸É ………. ‹Îµœ°ŠÁŒ¡µ³­nªœ Ò. œµ¥ „. Ó- - --- - (¨ŠÉ°º ) œµ¥ ¡.
Á—º°œ………… Ó.œµŠ ….
¡.«………….. œµ¥ „. ‹µÎ œ°ŠÁŒ¡µ³­nªœ…°Š˜œÂ„n œµ¥ . ­ªn œ…°Š
œµŠ …. ‡ŠÁ—¤·

ª´œšÉ¸ …………. Šn „¦¦¤­š· ›¦·Í ª¤ Ò. œµ¥ „. œµŠ …. šÉ¸—œ·Òž¨ŠšÂɸ -¥„Åžœ¸Ê¡-oœ‹µ„„µ¦Ò‹Îµœ°Š˜µ-¤­´ µ - 5136 IV 7228-1 (¨ŠÉ°º )…………….
‹Îµœ°ŠÁŒ¡µ³­nªœ Œ´¨Šªœ´ š¸É…..Á—º°œ….…....¡.«…..
Á—°º œ…………. (‡¦°-ž¨°—‹Îµœ°Š) Ó. œµŠ …. ÒÑ
¡.«. …………. ˜µ¤œ´ š¹„…°o ˜„¨Šž¨°—‹Îµœ°Š ¨Šª´œš…ɸ …. ÒÓÔÒ

Á—º°œ……….….¡.«. ….

œµ¥ „. Ò-- - - - - (¨Šº°É )……………..

š¸É—œ· ž¨Š‡ŠÁ®¨º°„µ¦‹Îµœ°Š¥´Š‡Š¤°¸ ¥˜¼n µ¤­´ µ
‹µÎ œ°ŠÁŒ¡µ³­nªœ Œ´ ¨Šª´œšÉ¸….Á—º°œ…….¡.«…..

®¤µ¥Á®˜» ­µ¦´‹—š³Á¸¥œÂž¨ŠÂ¥„ÃŒœ—š¸É ÒÓÔÒ ž¨°—‹Îµœ°ŠÅ¤n˜o°Š¥„¦µ¥„µ¦‹—‹Šo ˜°n ¥nµŠÄ—

˜´ª°¥nµŠ®¤µ¥Á¨… ÔÑ ˜µ¤¦³Á¥¸ …°o ÓÚ (Ô) ª¦¦‡­°Š † šÉ¸ oµœ (š.—. Ò)
† š­É¸ ªœ/Ŧn
„¦–­¸ ªn œ…°ŠŸ¼o‹Îµœ°ŠÁž}œÂž¨ŠÂ¥„ ‡Îµ…°‹—š³Á¸¥œ­š· ›·Â¨³œ˜· ·„¦¦¤ † š¸Éœµ
† šÉ¸ ..............
¨³„µ¦­°­ªœ­·š›Ä· œšÉ¸—·œ ž¦³Á£š ......Â.....nŠ.„...¦.…¦¤…­·š…›¦Í·…ª¤…….....†.... œ°„Á…˜
˜ÎµÂ®œnŠš¸—É œ· (‡¦° - ž¨°—‹Îµœ°Š) † ĜÁ…˜ Â¥„ Ò

¦³ªµŠ.........5..1..3..6...I.V....7..2..2..8...-..1........…..........................................……..˜µÎ ¨.........................................……......….....................................................…..
Á¨…šÉ—¸ ·œ.......................Ó....Ô.......................................………............…°ÎµÁ£°.....................................…...........................................……....................…..
®œµo ­Îµ¦ª‹...................Õ...Õ...Õ..........................................……..............‹Š´ ®ª´—...........................................................................................……........…….
̜—š¸—É ·œ
šÉ¸—·œÂž¨ŠšÉ¸Â¥„ÅžœÊ¸„µ¦‹Îµœ°Š¥´Š‡Š¤¸°¥n¼˜µ¤­´µ‹Îµœ°ŠÁŒ¡µ³­nªœŒ´¨Šª´œš¸É…….Á—º°œ……………..¡.«. …
Á‹oµ¡œ´„ŠµœšÉ¸—·œ. Á¨…š.¸É ...........................Ö....Ô...Ú..Ò.........................……..........................Á¨¤n ..........……Ö…Õ..………........................®œoµ......………….Ú…Ò..…...……......…..
‹Îµœªœš¸É—·œ.................Ó...................…....................Ŧn.....………………Ô ……….....................Šµœ.................…………ÖÑ…...….................…....˜µ¦µŠªµ

Ò. …µo ¡Á‹µo Ÿo¼¤¸œµ¤˜°n ޜʸ ¤‡¸ ªµ¤ž¦³­Š‡…r °‹—š³Á¥¸ œ­·š›·Â¨³œ˜· „· ¦¦¤Á„ɸ¥ª„´°­´Š®µ¦¤· š¦¡´ ¥rš„ɸ ¨µn ª…µo ŠœœÊ¸ ¨³Å—žo ’·µ–˜œÂ¨ªo
…°Ä®™o o°¥‡µÎ —oª¥‡ªµ¤­˜´ ¥r‹¦·Š ™µo …oµ¡Á‹µo Ä®o™°o ¥‡µÎ ŤÁn žœ} ‡ªµ¤‹¦Š· Ä®očo™o°¥‡ÎµœÊ¸¥´œ…oµ¡Á‹µo ĜšµŠ‡—°¸ µµÅ—o

Á¨…ž¦³‹Îµ˜ª´ ž¦³µœ

Ó. …µo ¡Á‹µo ........ÔÒÓ........œ.œœ..µ.µµ.¥¥Š...‡…„..............……..................... † †††† ††††† †† † Ÿ¼o ..™..°º...„..¦..¦…¤…­·š…›Í·.....….....…..

°µ¥» .......Ö....Ñ..,.Õ...Ö............. že ­´µ˜· ...................Å..š...¥......…………............. ·—µ / ¤µ¦—µÉº° ........................................................................…......…..
† í— † ®¤oµ¥ † ‡n¼­¤¦­É°º .................………….......…...………...........…............…...........……
°¥nš¼ ¸Éµo œ/®¤¼n µo œ ..................……....... Á¨…š¸É ........................ ˜¦°„/Ž°¥ ...........…...…................. ™œœ ..….......……..….....….....®¤š¼n ¸É ..…......……
˜Îµ¨/…ªŠ .....................….............°ÎµÁ£°/Á…˜ ..............…….................. ‹Š´ ®ª´— ..........….…...........…........®¤µ¥Á¨…Ú¦«´¡šr .............…............…
Á¨…ž¦³‹µÎ ˜ª´ ž¦³µœ
Ô. …µo ¡Á‹oµ ......................…œµ…¥ „................................ † †† † Ÿ¼o .™...º°..„..¦..…¦¤.­...·š...›..Í· ...…..……..
†††† †††††

°µ¥» .......Ö....Ñ................... že ­´µ˜· .....…..........Å..š...¥........................ —· µ / ¤µ¦—µÉº° ...............………............................…................…...........…..…
† í— † ®¤µo ¥ † ‡¼­n ¤¦­°ºÉ .....................……....................­´ µ˜· ………..…...…….........……
°¥šn¼ ¸Éµo œ/®¤n¼ oµœ ................................ Á¨…š¸É .....……............ ˜¦°„/Ž°¥ ..................……............. ™œœ ................……...…..........®¤nš¼ ¸É ...…......…...

˜Îµ¨/…ªŠ ................................. °µÎ Á£°/Á…˜ ................……..................‹´Š®ª—´ ......……......….…..............®¤µ¥Á¨…Ú¦«¡´ šr ..............….......…....

Õ. …µo ¡Á‹µo …°Â­—Š¦µ‡µš¦´¡¥šr Ʌ¸ °šµÎ œ˜· „· ¦¦¤œ¸ÊÁž}œÁŠ·œ .........................…….......................... µš ....…….......…............­˜µŠ‡r

Ö. …µo ¡Á‹oµ…°¦´ ¦°Šªµn

(Ò) …µo ¡Á‹oµÅ¤Ån —¦o ´Ã°œÂšœ®¦º°Á¡°Éº ž¦³Ã¥œr„n »‡‡¨˜nµŠ—µo ª

(Ó) ¦.Â.µ..‡..nŠµ..„š..¦.¦.¦.¡´ .¤.¥..­.šr .š·.ɸ..›.­.Í·¦.—.ª..Š.¤Å...ª˜..Äo .µ.œ¤...‡Õ..ε...….Á.°.ž..¨œ}..Š.¦.ª.µ.´œ.‡..šµ..š.…ɸ ..Âɸ ..…š..…o‹.Á¦—…·Šº°…œ…...…....…....…....…....¡.....«...…....…............................................................…...................……
(Ô)
(Õ) ..............................................................................……….................................................................................…...............……
(Ö) ..............................................................................………....................................................................…..........…...............……
ª´œš.¸É ................. Á—°º œ ...............................…........ ¡.«. ...........…….......
¨Š°ºÉ ..................œ...µ..Š...…....,..œ...µ..¥...‡................... Ÿ…¼o ° ™°º „¦¦¤­·š›·Í
¨Šº°É ..................œ...µ..¥...„................................. Ÿo¼…° ™º°„¦¦¤­·š›Í·
¨ŠºÉ° ........................................................... Ÿ­o¼ °­ªœ

(………………………………………)

­Îµ®¦´¡œ„´ ŠµœÁ‹µo ®œµo š¸É

Ò) ¦µ‡µž¦³Á¤·œšœ» š¦¡´ ¥.r .......................................………........……………...................………….µš..........…….…….............…..............­˜µŠ‡r
Ó) ̜—šÉ—¸ ·œÄ®¤¦n ³ªµŠ.....5..1..3..6...I.V....7…22…8.-...1................Á¨…š¸É—œ· ..........…....……ÓÕ…….......……..........®œµo ­µÎ ¦ª‹....................…Õ…ÕÖ………...............

̜—š—¸É œ· Á¨…š.ɸ .......................Ö…Ô…ÚÓ................….....Á¨¤n .................…………Ö.Õ......................……..®œoµ…………………..…Ú…Ó….………………
‹Îµœªœš—¸É œ· ....................…...-......………......….......Ŧn...............……......……Ô………....................Šµœ...............……....…...Ö...Ñ..…...........˜µ¦µŠªµ
‡ŠÁ®¨°º ..................................Ó.......………......….....Ŧn.............……..........……- ………..............….Šµœ.........…….........-…..…..................˜µ¦µŠªµ
Ô) ŗ‹o —š³Á¸¥œÂ¨oªÂ˜nªœ´ š.ɸ ..............…...............Á—º°œ...............................¡.«. ……………….

¨Š°ºÉ ...................................................................
( ................................................................. )
Á‹µo ¡œ´„Šµœš—ɸ ·œ

˜ª´ °¥nµŠ®¤µ¥Á¨… ÔÑ ˜µ¤¦³Á¸¥…°o ÓÚ (Ô) ª¦¦‡­°Š † š¸Éµo œ (š.—. Ò)
† š­¸É ªœ/Ŧn
† š¸Éœµ
‡Îµ…°‹—š³Á¥¸ œ­š· ›Â· ¨³œ˜· „· ¦¦¤ † šÉ¸ ..............
¨³„µ¦­°­ªœ­·š›Ä· œš¸—É œ· ž¦³Á£š ......Â.....Šn .„...¦.…¦¤…­·š…›¦Í·…ª¤…….....†.... œ°„Á…˜
˜ÎµÂ®œnŠšÉ—¸ œ·
(‡¦° - ž¨°—‹Îµœ°Š) † ĜÁ…˜ Â¥„ Ó

¦³ªµŠ...........................5..1..3..6...I.V....7.…22.8...-..1....................................……..˜µÎ ¨.........................................……......….....................................................…..
Á¨…šÉ¸—·œ.......................Ó....Ô.......................................………............…°µÎ Á£°.....................................…...........................................……....................…..
®œoµ­Îµ¦ª‹...................Õ...Õ...Õ..........................................……..............‹´Š®ª´—...........................................................................................……........…….
̜—š¸—É ·œ
Á¨…š.¸É ...........................Ö....Ô...Ú..Ò.........................……..........................Á¨n¤..........……Ö…Õ..………........................®œµo ......………….Ú…Ò..…...……......…..
šÉ¸—·œÂž¨ŠšÉ¸Â¥„ÅžœÊ¸¡oœ‹µ„„µ¦‹Îµœ°Š ˜µ¤­´µ‹Îµœ°ŠÁŒ¡µ³­nªœ Œ´¨Šª´œš¸É…….Á—º°œ…………¡.«. ….‹ÎµœªœšÉ¸—·œ.................Ó...................…....................Ŧn.....………………- ……….....................Šµœ.................…………- …...….................…....˜µ¦µŠªµ
˜µ¤´œš¹„…o°˜„¨Šž¨°—‹Îµœ°Š ¨Šª´œš¸É…….Á—º°œ…………¡.«. ….
Ò. …oµ¡Á‹µo Ÿ¼¤o œ¸ µ¤˜n°Åžœ¸Ê ¤‡¸ ªµ¤ž¦³­Š‡…r °‹—š³Á¸¥œ­š· ›·Â¨³œ·˜·„¦¦¤Á„ɸ¥ª„´°­Š´ ®µ¦¤· š¦´¡¥rš¸„É ¨µn ª…µo ŠœœÊ¸ ¨³Å—žo ’·µ–˜œÂ¨ªo
Á‹oµ¡œ´„ŠµœšÉ¸ ·—œ …°Ä®o™°o ¥‡Îµ—oª¥‡ªµ¤­´˜¥r‹¦Š· ™oµ…µo ¡Á‹µo Ä®o™o°¥‡ÎµÅ¤Án ž}œ‡ªµ¤‹¦·ŠÄ®očo™o°¥‡ÎµœÊ¥¸ ´œ…µo ¡Á‹oµÄœšµŠ‡—°¸ µµÅ—o

Á¨…ž¦³‹µÎ ˜´ªž¦³µœ

Ó. …oµ¡Á‹µo ...........ÔÓ.Ò.......œ.œœ..µ.µµ.¥Š.¥..‡….„..........……..................... † †††† ††††† †† † Ÿ¼o .™...°º ..„..¦..¦.…¤­…š· …›·Í .....….....…..

°µ¥» ............×..Ñ...,.Õ...Ù......... že ­´µ˜· .............Å..š...¥............…………............. —· µ / ¤µ¦—µ°ºÉ ........................................................................…......…..
† í— † ®¤oµ¥ † ‡¼­n ¤¦­°Éº .................………….......…...………...........…............…...........……
°¥šn¼ ¸É µo œ/®¤n¼oµœ ..................……....... Á¨…šÉ¸ ........................ ˜¦°„/Ž°¥ ...........…...…................. ™œœ ..….......……..….....….....®¤n¼š¸É ..…......……
˜Îµ¨/…ªŠ .....................….............°µÎ Á£°/Á…˜ ..............…….................. ‹Š´ ®ª´— ..........….…...........…........®¤µ¥Á¨…Ú¦«´¡šr .............…............…

Á¨…ž¦³‹µÎ ˜ª´ ž¦³µœ

Ô. …µo ¡Á‹oµ ..................œ...µ.Š………. ............................... † †††† ††††† †† † Ÿo¼ ..™..°º..„...¦.…¦¤..­..·š...›..·Í...…..……..

°µ¥» ............Õ...Ö............... že ­´ µ˜· .....….....Å..š...¥............................. ·—µ / ¤µ¦—µÉº° ...............………............................…................…...........…..…
† í— † ®¤oµ¥ † ‡n¼­¤¦­Éº° .....................……....................­´ µ˜· ………..…...…….........……
°¥¼nš¸Éµo œ/®¤¼n µo œ ................................ Á¨…šÉ¸ .....……............ ˜¦°„/Ž°¥ ..................……............. ™œœ ................……...…..........®¤šn¼ ɸ ...…......…...

˜µÎ ¨/…ªŠ ................................. °µÎ Á£°/Á…˜ ................……..................‹Š´ ®ª´— ......……......….…..............®¤µ¥Á¨…Ú¦«¡´ šr ..............….......…....

Õ. …µo ¡Á‹oµ…°Â­—Š¦µ‡µš¦¡´ ¥šr ¸…É °šµÎ œ·˜·„¦¦¤œ¸ÁÊ ž}œÁŠ·œ .........................…….......................... µš ....…….......…............­˜µŠ‡r

Ö. …oµ¡Á‹oµ…°¦´¦°Šªµn

(Ò) …oµ¡Á‹oµÅ¤Ån —¦o ´Ã°œÂšœ®¦º°Á¡°Éº ž¦³Ã¥œÂr „n»‡‡¨˜nµŠ—µo ª

(Ó) ¦µ‡µš¦´¡¥rš¸É­—ŠÅªÄo œ Õ. Áž}œ¦µ‡µšÉ¸Âš‹o ¦Š·
(Ô) .Â.....nŠ..„..¦..¦..¤...­..·š...›...Í·¦..ª..¤....˜...µ.¤...‡..ε..…...°..¨..Š..ª..œ´...š...…ɸ....….……….Á…—º°..œ...…....…....…....…....…....….....¡...«...…....….................................................…...................……
(Õ) ..............................................................................……….................................................................................…...............……
(Ö) ..............................................................................………....................................................................…..........…...............……
ªœ´ š.ɸ ................. Á—°º œ ...............................…........ ¡.«. ...........…….......
¨Šº°É ...................œ...µ..¥...„....,..œ...µ..¥...‡.................. Ÿ…¼o ° ™º°„¦¦¤­š· ›·Í
¨ŠÉ°º ...................œ...µ..Š...…................................ Ÿ¼…o ° ™º°„¦¦¤­š· ›Í·
¨ŠºÉ° ........................................................... Ÿ­¼o °­ªœ

(………………………………………)

­Îµ®¦´ ¡œ„´ ŠµœÁ‹oµ®œµo šÉ¸

Ò) ¦µ‡µž¦³Á¤œ· šœ» š¦¡´ ¥.r .......................................………........……………...................………….µš..........…….…….............…..............­˜µŠ‡r
Ó) ̜—š¸—É œ· Ä®¤¦n ³ªµŠ..............5..1..3.…6I…V 7..2..2..8..-..1..........Á¨…š—¸É ·œ..........…....……Ó…Ö….......……..........®œoµ­Îµ¦ª‹....................…Õ…Õ×………...............

̜—š¸É—œ· Á¨…š.¸É .............Ö...Ô...Ú..Ô..……................….....Á¨n¤.................…………Ö....Õ...................……..®œoµ…………………..…Ú…Ô….………………
‹ÎµœªœšÉ¸—œ· ....................…Ò.........………......….......Ŧn...............……......……-………....................Šµœ...............……....…..-......…...........˜µ¦µŠªµ
‡ŠÁ®¨º°..............................Ò...........………......….....Ŧn.............……..........……………..............….Šµœ.........…….........…..…..................˜µ¦µŠªµ
Ô) ŗo‹—š³Á¥¸ œÂ¨oªÂ˜ªn œ´ š.¸É ..............…...............Á—°º œ...............................¡.«. ……………….

¨ŠÉº° ....................................................................
( .................................................................. )
Á‹µo ¡œ´„Šµœš¸É—·œ

˜´ª°¥nµŠ®¤µ¥Á¨… ÔÑ ˜µ¤¦³Á¥¸ …o° ÓÚ (Ô) ª¦¦‡­°Š † š¸Éµo œ (š.—. Ò)
† š¸­É ªœ/Ŧn
† š¸œÉ µ
‡Îµ…°‹—š³Á¥¸ œ­·š›Â· ¨³œ˜· ·„¦¦¤ † šÉ¸ ..............
¨³„µ¦­°­ªœ­·š›Ä· œšÉ—¸ œ· ž¦³Á£š ......Â.....Šn .„...¦.…¦¤…­š· …›·Í¦…ª¤…….....†.... œ°„Á…˜
˜µÎ ®œnŠš—¸É œ·
(‡¦° - ž¨°—‹µÎ œ°Š) † ĜÁ…˜ ž¨Š‡ŠÁ®¨°º

¦³ªµŠ...........................5..1..3..6...I.V....7.…22.8...-..1....................................……..˜Îµ¨.........................................……......….....................................................…..
Á¨…š¸—É œ· .......................Ó....Ô.......................................………............…°ÎµÁ£°.....................................…...........................................……....................…..
®œoµ­µÎ ¦ª‹...................Õ...Õ...Õ..........................................……..............‹Š´ ®ª—´ ...........................................................................................……........…….
̜—š—¸É ·œ
Á¨…š.ɸ ...........................Ö....Ô...Ú..Ò.........................……..........................Á¨n¤..........……Ö…Õ..………........................®œoµ......………….Ú…Ò..…...……......…..
š¸É—·œÂž¨Š‡ŠÁ®¨º°¡oœ‹µ„„µ¦‹Îµœ°Š ˜µ¤­´µ‹Îµœ°ŠÁŒ¡µ³­nªœ Œ´¨Šª´œš¸É…….Á—º°œ…………‹µÎ œªœš¸—É œ· .................Ò...................…....................Ŧn.....………………- ……….....................Šµœ.................…………- …...….................…....˜µ¦µŠªµ
¡.«. …. ˜µ¤´œš¹„…o°˜„¨Šž¨°—‹Îµœ°Š ¨Šª´œšÉ¸…….Á—º°œ…………¡.«. ….
Ò. …oµ¡Á‹oµŸ¤o¼ ¸œµ¤˜°n Şœ¸Ê ¤‡¸ ªµ¤ž¦³­Š‡…r °‹—š³Á¥¸ œ­š· ›Â· ¨³œ·˜„· ¦¦¤Á„¥É¸ ª„´ °­´Š®µ¦¤· š¦´¡¥šr „¸É ¨µn ª…oµŠœœ¸Ê ¨³Å—ož’·µ–˜œÂ¨ªo
Á‹oµ¡œ´„Šµœš¸É—·œ …°Ä®o™o°¥‡µÎ —oª¥‡ªµ¤­´˜¥r‹¦Š· ™oµ…µo ¡Á‹oµÄ®o™o°¥‡µÎ ŤÁn ž}œ‡ªµ¤‹¦Š· Ä®očo™o°¥‡ÎµœÊ¥¸ ´œ…oµ¡Á‹oµÄœšµŠ‡—°¸ µµÅ—o

Á¨…ž¦³‹Îµ˜ª´ ž¦³µœ

Ó. …oµ¡Á‹µo ...........ÔÓ.Ò......œ.œœ..µ.µµ.¥Š.¥..‡….„...........……..................... † †††† ††††† †† † Ÿo¼ .™...°º ..„..¦..¦.…¤­…š· …›·Í .....….....…..

°µ¥» ............×..Ñ...,.Õ...Ù......... že ­´ µ˜· .............Å..š...¥............…………............. ·—µ / ¤µ¦—µÉº° ........................................................................…......…..
† í— † ®¤µo ¥ † ‡­¼n ¤¦­É°º .................………….......…...………...........…............…...........……
°¥šn¼ ɝ¸ oµœ/®¤n¼ µo œ ..................……....... Á¨…š¸É ........................ ˜¦°„/Ž°¥ ...........…...…................. ™œœ ..….......……..….....….....®¤nš¼ ɸ ..…......……
˜µÎ ¨/…ªŠ .....................….............°µÎ Á£°/Á…˜ ..............…….................. ‹´Š®ª´— ..........….…...........…........®¤µ¥Á¨…Ú¦«¡´ šr .............…............…

Á¨…ž¦³‹Îµ˜´ªž¦³µœ

Ô. …oµ¡Á‹oµ ..................œ...µ.Š………. ............................... † †††† ††††† †† † Ÿ¼o ..™..°º..„...¦.…¦¤..­..·š...›..Í·...…..……..

°µ¥» ............Õ...Ö............... že ­´ µ˜· .....….....Å..š...¥............................. ·—µ / ¤µ¦—µÉº° ...............………............................…................…...........…..…
† í— † ®¤µo ¥ † ‡­¼n ¤¦­É°º .....................……....................­´µ˜· ………..…...…….........……
°¥¼nš¸Éµo œ/®¤n¼oµœ ................................ Á¨…šÉ¸ .....……............ ˜¦°„/Ž°¥ ..................……............. ™œœ ................……...…..........®¤¼nš¸É ...…......…...

˜Îµ¨/…ªŠ ................................. °ÎµÁ£°/Á…˜ ................……..................‹Š´ ®ª´— ......……......….…..............®¤µ¥Á¨…Ú¦«´¡šr ..............….......…....

Õ. …oµ¡Á‹µo …°Â­—Š¦µ‡µš¦´¡¥šr …¸É °šµÎ œ˜· ·„¦¦¤œ¸ÊÁž}œÁŠ·œ .........................…….......................... µš ....…….......…............­˜µŠ‡r

Ö. …µo ¡Á‹oµ…°¦´ ¦°Šªnµ

(Ò) …oµ¡Á‹oµÅ¤Ån —¦o ´Ã°œÂšœ®¦º°Á¡°ºÉ ž¦³Ã¥œÂr „n‡» ‡¨˜µn Š—µo ª

(Ó) ¦µ‡µš¦´¡¥ršÉ¸Â­—ŠÅªoĜ Õ. Ážœ} ¦µ‡µš¸Éš‹o ¦Š·
(Ô) .Â.....nŠ..„..¦..¦..¤...­..š·...›...Í·¦..ª..¤....˜...µ.¤...‡..µÎ..…...°..¨..Š..ª..´œ...š...…¸É....….……….Á…—°º ..œ...…....…....…....…....…....….....¡...«...…....….................................................…...................……
(Õ) ..............................................................................……….................................................................................…...............……
(Ö) ..............................................................................………....................................................................…..........…...............……
ª´œš.ɸ ................. Á—°º œ ...............................…........ ¡.«. ...........…….......
¨Š°Éº ...................œ...µ..¥...„....,..œ...µ..Š...….................. Ÿ…¼o ° ™°º „¦¦¤­·š›Í·
¨ŠÉº° ...................œ...µ..¥...‡................................ Ÿo…¼ ° ™º°„¦¦¤­š· ›·Í
¨ŠÉ°º ........................................................... Ÿo¼­°­ªœ

(………………………………………)

­Îµ®¦´ ¡œ´„ŠµœÁ‹µo ®œµo š¸É

Ò) ¦µ‡µž¦³Á¤œ· šœ» š¦¡´ ¥.r .......................................………........……………...................………….µš..........…….…….............…..............­˜µŠ‡r
Ó) ̜—š—ɸ ·œÄ®¤¦n ³ªµŠ...................……....................Á¨…š—ɸ ·œ..........…....………….......……..........®œoµ­Îµ¦ª‹....................……………...............

̜—š¸É—œ· Á¨…š.ɸ .......................……................….....Á¨n¤.................………….......................……..®œoµ…………………..……….………………
‹µÎ œªœšÉ—¸ ·œ....................….........………......….......Ŧn...............……......……………....................Šµœ...............……....…........…...........˜µ¦µŠªµ
‡ŠÁ®¨°º .........................................………......….....Ŧn.............……..........……………..............….Šµœ.........…….........…..…..................˜µ¦µŠªµ
Ô) ŗo‹—š³Á¥¸ œÂ¨oªÂ˜nªœ´ š.ɸ ..............…...............Á—°º œ...............................¡.«. ……………….

¨Š°Éº ....................................................................
( .................................................................. )

Á‹µo ¡œ´„Šµœš¸É—·œ

˜ª´ °¥nµŠ®¤µ¥Á¨… ÔÑ ˜µ¤¦³Á¸¥…°o ÓÚ (Ô) ª¦¦‡­°Š (š.—. Ò×)

œ´ š„¹ …°o ˜„¨ŠÁ¦Éº°Šž¨°—‹µÎ œ°Š

š¸—É ·œ
¦³ªµŠ.......…5…13…6 I…V …72…28..-..1......................…..˜Îµ¨...........……………………………..…………….............
Á¨…šÉ—¸ œ· …………Ó…Ô………®œoµ­Îµ¦ª‹......……Õ…Õ...............°ÎµÁ£°..............…........……................................
̜—®¤µ¥Á¨…š…ɸ ……………Ö…Ô…ÚÒ………….……….‹Š´ ®ª´—................................…….…...........................
š¸Éªnµ„µ¦…………..….…………………………
ª´œšÉ¸…………Á—°º œ………….…….…¡.«. ……………

Á¨…ž¦³‹Îµ˜ª´ ž¦³µœ

…oµ¡Á‹oµ ..……….....œ...µ.¥...........…Ÿ…¦¼o ´…‹Îµ..œ.…°Š.........................………....... † †††† ††††† †† †
..……….....œ..µ..¥...„........…Ÿ…¼o‹Îµ…œ°..Š.….........................………....... † †††† ††††† †† †

°µ¥» ................ že Á°Êº µ˜·…………ÖÑ…,Õ.…Ö… ­´ µ˜·.............Å..š...¥......... ·—µ / ¤µ¦—µºÉ° ..Å..š..¥....….….........................................
°¥¼nšÉ¸ µo œ/®¤n¼µo œ ...................... Á¨…š¸É ................. ˜¦°„/Ž°¥ ....…….........….......... ™œœ ..........…….…………..®¤š¼n ɸ .....…...
˜µÎ ¨/…ªŠ ...................... °ÎµÁ£°/Á…˜ ............................ ‹´Š®ª—´ ...…......………................®¤µ¥Á¨…Ú¦«¡´ šr .….....................
…///°//ž//’///· //µ//–///˜//œ///Â//¨//³//Ä/®///™o//°o//¥//‡//ε//˜//n°/ ……ŗ…ošÎµ…œ´…š…¹„……o°…˜„…¨Š…˜…n°Á‹…oµ¡…œ…´„Š…µœ…š…ɸ—·œ……………………………………………………..
—///ªo //¥/‡///ª//µ/¤//­///´˜//¥//r‹//¦//·Š —´Š˜°n ޜʸ : -
………………o°…Ò.…˜…µ¤…š……¸É oµ…¡Á…‹oµš…´ÊŠ…­°…Š …iµ¥…ŗ…o‹…—š…³Á…¸¥.œ…‹…圅°Š…ÁŒ…¡µ…³­.…ªn œ…š…ɸ—œ· …Â…ž¨…ŠÁ…‡¦…°Éº Š…®¤…µ…¥……µo Š…œ..œ…¸ÊÅ…ª˜o …°n „…´œ…˜…µ¤…­´……µ .
…‹µÎ œ…°…ŠÁŒ…¡…µ³…­nª…œ…Œ…´ …¨Š…ª´œ…š…¸É…..….Á—…º°œ………………………¡….«…. …….…´—…œ…¸Ê Ÿ…™o¼ º°…„¦…¦¤…­…·š›.…·ÄÍ œ…š…¸É—·œ…ž…¨…Šœ…ʸŗ…o……°¦…Š´ ª.´—.……nŠ„…¦…¦¤…­š·…›…Í·¦ª…¤.
…¨…³Á¦…°Éº …ŠÂ…nŠ…Â¥…„Á…­¦…‹È ¡…¦…°o ¤…š…¸É‹³…‹—…š³…Á…¸¥œ…Â…¨oª………µo ¡.Á…‹oµ…œ…µ¥….…Ÿ…o¼¦´ .…‹Îµ…œ°…Š …¥·œ…¥°…¤Ä…®…o‹—…š³…Á…¥¸ œ…Â…Šn..„…¦¦…¤…­·š…›…¦·Í ª…¤ …×…¥Ä…®o .
…„µ…¦‹…µÎ œ…°Š…‡Š…‡¦…°…˜…·—…°¥…n¼ÁŒ…¡µ…³š.…¸É—·œ…Ã…Œœ…—…šÉ¸—…·œ…Á¨……š…¸É Ö…Ô…ÚÓ…Ž…ɹŠ…Áž…}œ……°Š…œ…µ¥.…„.…­…nªœ…š…¸É—·œ…Â…ž¨…ŠÃ…Œ…œ—..š…¸É—…·œÁ…¨……š…¸É Ö…ÔÚ…Ô….
…¨…³ …ÖÔ…Ú…Ò …ŽÉ¹Š…Áž…}œ……°…Šœ…µŠ………. Â…¨…³ œ…µ…¥ ‡…. …˜µ…¤¨…µÎ —.…´ …Ť…n¤¸„…µ¦…‹…εœ.°…Š…‡¦…°…˜…·—Å…žÂ…˜…nž¦…³„…µ¦…ė……..……………………….
………………o°…Ó…. ……oµ…¡Á‹…oµš…´ÊŠ…­°…Š .…iµ¥…˜„…¨Š…¥·œ…¥…°¤…„´œ…Ä®…o¡…œ…„´ Š…µœ…šÉ¸—…·œ…‹—…š…³Á…¸¥œ.……nŠ…„¦…¦¤…­·š…›…¦·Í ª…¤Ä…®…o…µo ¡..…Á‹µo…˜µ…¤‡…ª…µ¤…ž¦…³­…Š‡. r
…—´Š…„¨…nµª……oµ…Š˜…oœ……………………………………….……………….…………………………………..……………………….
……………´œ…š¹„………o°˜…„…¨Š…œ¸Êš…εŅª.o …®œ…Š¹É Œ……´…Á„…È Å…ªo …–…­µÎ …œ´„…Šµ…œ…šÉ—¸ …œ· …š…Ê´Š­…°Š… iµ.…¥Å…—o˜…¦ª…‹—…¼…´œš…¹„……o°…˜…„¨..Š…¨…³…Á…oµ…ċ………o°‡…ªµ…¤.
…˜¨…°—…Â…¨oª…‹Š¹…ŗ…¨o …Š¨…µ¥…¤°º ……º°É ®…¦º°…¨…µ¥…¡·¤…¡…œr Ê·ª…¤º°…Å…ªÁo ž.…}œ®…¨…´„“…µœ…˜…°n ®.…œoµ…¡…¥µ…œÂ…¨³…Á‹…oµ¡…œ…„´ Š…µœ…š¸É—…·œ…..……………………….

………………………………….……………………………………………….…………………………..…………………….
……………………………………………………….………¨Š…Éº°………….……………………œ……µ¥……….………………………………Ÿ¼¦o ..´ …‹Îµ…œ…°Š……………….
………………………………….……………………………¨Š…Éº°………………………………œ.……µ¥……„….………………………………Ÿ¼o‹…εœ..°…Š………………….
……………………………………………………….………¨Š…Éº°………….…………………………………………………………………¡¥..µ…œ…………………….
………………………………….……………………………¨Š…°Éº ……………………………….……………………………………………¡¥…µœ..…………………….

……………………………………………………….……………….…………………………………..……………………….
……………´œ…š¹„………o°˜…„¨…Š…œÅ¸Ê …—oš…ε˜.…n°®…œ…oµ ……………………………………….…………………………..…………………….
……………………………………………………….………¨Š…É°º ………….…………………………………………………………………Á‹µo..¡…œ…´„Š…µœ…š…ɗ¸ œ· ………….
……………………………………………………….………………ž¦.…³š…´˜…¦…µ˜…ε…®œ…nŠ…Áž}œ…­…ε‡…´ ……..……………………….

………………………………….……………………………………………….…………………………..…………………….

……………………………………………………….……………….…………………………………..……………………….

………………………………….……………………………………………….…………………………..…………………….

˜ª´ °¥nµŠ®¤µ¥Á¨… ÔÑ ˜µ¤¦³Á¸¥…°o ÓÚ (Ô) ª¦¦‡­°Š (¦µ¥„µ¦‹—š³Á¸¥œ ž¨ŠÁ—¤· ̜—š¸É ÖÔÚÒ)
­µ¦´‹—š³Á¥¸ œ

Áœº°Ê šÉ—¸ ·œ Áœ°Êº šÉ¸—œ· ¦³ªµŠ Á‹µo ¡œ´„Šµœš—ɸ ·œ
Á¨…š—¸É ·œ ¨Š¨µ¥¤°º °ºÉ
‹—š³Á¸¥œ ž¦³Á£š„µ¦ Ÿ¼oÄ®o­´ µ Ÿ¼o¦´­´ µ ˜µ¤­´µ ‡ŠÁ®¨°º
ªœ´ Á—º°œ že ‹—š³Á¸¥œ ̜—š¸É—·œÄ®¤n ž¦³š´ ˜¦µ
œµ¥ . Ŧn Šµœ ˜µ¦µŠ Ŧn Šµœ ˜µ¦µŠ
Ÿ¼¦o ´ ‹µÎ œ°Š ªµ ªµ

ª´œš…¸É ……….. ‹Îµœ°ŠÁŒ¡µ³­nªœ Ò. œµ¥ „. œµ¥ „. Ó Ô ÖÑ - - - - (¨ŠÉ°º ) œµ¥ ¡.
Á—°º œ…………. Ó.œµŠ …. œµ¥ „. ‹µÎ œ°ŠÁŒ¡µ³­nªœ…°Š˜œÂ„n œµ¥ .
¡.«. …………. Šn „¦¦¤­·š›Í¦· ª¤ Ô.œµ¥ ‡. ­ªn œ…°Š œµŠ …. ‡ŠÁ—¤·
(‡¦°-ž¨°—‹Îµœ°Š)
ªœ´ š¸É …………. Ò. œµ¥ „. - Ô ÖÑ Ó - - 5136 IV7228-1 (¨Š°Éº )……………
Á—°º œ…………. Ó.œµŠ …. š¸É—·œÂž¨ŠšÂɸ ¥„ÅžœÊ„¸ µ¦‹µÎ œ°Š¥Š´ ‡Š¤°¸ ¥n¼ ˜µ¤­´µ
¡.«. …………. Ô.œµ¥ ‡. ÓÕ
‹µÎ œ°ŠÁŒ¡µ³­nªœ Œ´¨Šª´œšÉ¸……Á—°º œ.……¡.«….. ÖÔÚÓ

œµŠ …. šÉ¸—Ò·œÂž¨ŠšÉ¸Â-¥„Åžœ¸Ê¡-œo ‹µ„„µ¦‹Ò地Š˜µ¤-­´ µ‹µÎ œ-°Š 5136IV7228-1 (¨Š°ºÉ )……………
ÁŒ¡µ³­nªœ Œ´¨Šª´œš…ɸ .Á—º°œ….……¡.«. ….
˜µ¤´œš¹„…°o ˜„¨Šž¨°—‹Îµœ°Š ¨Šª´œš…¸É .. ÓÖ
ÖÔÚÔ

Á—°º œ……….…¡.«. ….

œµ¥ ‡. Ò- - - - - - (¨Š°ºÉ )……………
š¸—É ·œÂž¨Š‡ŠÁ®¨º°¡oœ‹µ„„µ¦‹µÎ œ°Š˜µ¤­´µ‹Îµœ°Š

ÁŒ¡µ³­nªœ Œ´¨Šª´œš…¸É .Á—º°œ….……¡.«. ….

˜µ¤´œš¹„…°o ˜„¨Šž¨°—‹Îµœ°Š ¨Šª´œš…ɸ ..

Á—º°œ…………..¡.«. ….

˜ª´ °¥nµŠ®¤µ¥Á¨… ÔÑ ˜µ¤¦³Á¸¥…o° ÓÚ (Ô) ª¦¦‡­°Š (¦µ¥„µ¦‹—‹Šo šÉ¸—œ· ž¨Šš¸ÉÂ¥„ŞĮ¤Ãn Œœ—šÉ¸ ÖÔÚÓ)
­µ¦´ ‹—š³Á¸¥œ

Áœ°Êº š—¸É ·œ Áœº°Ê š¸É—œ· ¦³ªµŠ Á‹oµ¡œ´„ŠµœšÉ¸—·œ
Á¨…š¸—É œ· ¨Š¨µ¥¤º°ºÉ°
‹—š³Á¸¥œ ž¦³Á£š„µ¦ Ÿo¼Ä®­o ´µ Ÿo¼¦´ ­´µ ˜µ¤­´µ ‡ŠÁ®¨º° ̜—šÉ¸—·œÄ®¤n ž¦³š´ ˜¦µ
ª´œ Á—°º œ že ‹—š³Á¥¸ œ
œµ¥ . Ŧn Šµœ ˜µ¦µŠ Ŧn Šµœ ˜µ¦µŠ - (¨Š°Éº ) œµ¥ ¡.
Ÿ¦o¼ ´ ‹Îµœ°Š ªµ ªµ ªœ´ š…¸É ……………
Á—º°œ……………...
ª´œš…ɸ ……….. ‹µÎ œ°ŠÁŒ¡µ³­nªœ œµ¥ „. - Ô ÖÑ --- ¡.«. ………………
Á—º°œ…………. (‡¦°‹µÎ œ°Š) (¨ŠºÉ°)……………
¡.«. …………. „µ¦‹µÎ œ°Š¥Š´ ‡Š¤°¸ ¥¼n˜µ¤­´µ‹Îµœ°ŠÁŒ¡µ³­nªœ
Œ´¨Šª´œš…¸É ….Á—º°œ………….¡.«……

˜ª´ °¥nµŠ®¤µ¥Á¨… ÔÒ ˜µ¤¦³Á¥¸ …o° ÓÚ (Õ) † šÉ¸ µo œ (š.—. Ò)

† šÉ­¸ ªœ/Ŧn
¨³„µ¦­°­ª‡œÎµ…­°š· ‹›—Ä· œšš³Áɸ—œ· ¸¥œž­¦š·³Á›£·Âš¨³...œ..˜·.ž..·„.¨.¦.°.¦.—.¤.‹.…µÎ œ…°Š…………..†††......œšš. œÉ¸É¸°..„µ..Á.…...˜......
˜ÎµÂ®œnŠš—ɸ ·œ † ĜÁ…˜

¦³ªµŠ..........................................…..........................................……..˜Îµ¨.........................................……......….....................................................…..

Á¨…šÉ—¸ œ· ..................................................................………............…°ÎµÁ£°.....................................…...........................................……....................…..

®œoµ­µÎ ¦ª‹...................................................................……..............‹´Š®ª´—...........................................................................................……........…….
̜—š—ɸ ·œ
Á¨…š.ɸ .............................................................……..........................Á¨¤n ..........………..………........................®œoµ......………….…..…...……......…..
‹ÎµœªœšÉ¸—œ· .............................Ò.......…....................Ŧn.....………………- ……….....................Šµœ.................…………- …...….................…....˜µ¦µŠªµ

šÉ¸—·œÂž¨Šœ¸Ê¡oœ‹µ„„µ¦‹Îµœ°Š˜µ¤­´µ‹Îµœ°Š Œ´¨Šª´œšÉ¸….Á—º°œ…….…¡.«…... Ò. …µo ¡Á‹oµŸo¼¤œ¸ µ¤˜°n ޜʸ ¤¸‡ªµ¤ž¦³­Š‡…r °‹—š³Á¸¥œ­š· ›Â· ¨³œ˜· ·„¦¦¤Á„ɸ¥ª„´°­´Š®µ¦·¤š¦´¡¥ršÉ„¸ ¨nµª…µo ŠœœÊ¸ ¨³Å—žo ’·µ–˜œÂ¨ªo
˜µ¤´œš¹„…o°˜„¨Šž¨°—‹Îµœ°Š ¨Šª´œšÉ¸…..Á—º°œ………¡.«…… …°Ä®™o °o ¥‡µÎ —ªo ¥‡ªµ¤­´˜¥‹r ¦Š· ™µo …µo ¡Á‹µo Ä®™o o°¥‡µÎ ŤÁn žœ} ‡ªµ¤‹¦Š· Ä®očo™o°¥‡µÎ œÊ¥¸ ´œ…µo ¡Á‹oµÄœšµŠ‡—¸°µµÅ—o

Á‹oµ¡œ´„ŠµœšÉ¸—·œ Á¨…ž¦³‹µÎ ˜´ªž¦³µœ

Ó. …µo ¡Á‹oµ ................œ...µ..¥...…........……..................... † †††† ††††† †† † Ÿ¼o ....¦..´...‹..兜…°Š….....….....…..

°µ¥» .............................. že ­´µ˜· .................Å..š...¥........…………............. —· µ / ¤µ¦—µºÉ° ........................................................................…......…..
† í— † ®¤µo ¥ † ‡¼­n ¤¦­°Éº .................………….......…...............…............…...........…………..
°¥¼nš¸É oµœ/®¤¼n µo œ ..................……....... Á¨…š¸É ........................ ˜¦°„/Ž°¥ ...........…...…................. ™œœ ..….......……..….....….....®¤š¼n ¸É ..…......……
˜Îµ¨/…ªŠ .....................….............°ÎµÁ£°/Á…˜ ..............…….................. ‹Š´ ®ª—´ ..........….…...........…........®¤µ¥Á¨…Ú¦«¡´ šr .............…............…

Á¨…ž¦³‹µÎ ˜ª´ ž¦³µœ

Ô. …µo ¡Á‹oµ ..................œ...µ.¥…„…. ............................... † †††† ††††† †† † Ÿ¼o ........‹..兜.°..Š.........…..……..

°µ¥» .............................. že ­´µ˜· .....…............Å..š...¥...................... —· µ / ¤µ¦—µº°É ...............………............................…................…...........…..…
† í— † ®¤oµ¥ † ‡n­¼ ¤¦­º°É .....................……....................­´ µ˜· ………..…...…….........……
°¥nš¼ É¸ oµœ/®¤n¼ µo œ ................................ Á¨…š¸É .....……............ ˜¦°„/Ž°¥ ..................……............. ™œœ ................……...…..........®¤nš¼ ɸ ...…......…...

˜µÎ ¨/…ªŠ ................................. °ÎµÁ£°/Á…˜ ................……..................‹´Š®ª—´ ......……......….…..............®¤µ¥Á¨…Ú¦«¡´ šr ..............….......…....

Õ. …µo ¡Á‹oµ…°Â­—Š¦µ‡µš¦´¡¥šr ¸…É °šµÎ œ·˜·„¦¦¤œÊÁ¸ žœ} ÁŠ·œ .........................…….......................... µš ....…….......…............­˜µŠ‡r

Ö. …oµ¡Á‹oµ…°¦´¦°Šªnµ

(Ò) …oµ¡Á‹oµÅ¤Ån —¦o ´ ðœÂšœ®¦°º Á¡º°É ž¦³Ã¥œr„n ‡» ‡¨˜nµŠ—µo ª

(Ó) ¦µ‡µš¦¡´ ¥šr Âɸ ­—ŠÅªoĜ Õ. Áž}œ¦µ‡µš¸Éš‹o ¦Š·
(Ô) .š...ɗ¸ ..·œ...Â..ž...¨..Š..œ...Âʸ ..¥..„...¤..µ..‹..µ..„..Ã..Œ...œ...—..š...…ɸ ......….....°..µÎ..Á…£°…………....…....…......Å..—..¡o...oœ...‹..µ..„..„...µ.¦..‹...µÎ .œ...°..Š..˜...µ..¤..­...´......µ..‹..ε..œ..°...Š..Œ.....´...¨..Š..ª.…´œš...…¸É ....…....…....…....…….…

˜...µ.¤......´œ..š...„¹..…...o°..˜...„..¨...Š..¨...Š..ª..œ´ ...š..…¸É....…....…....…....…....…..............……….................................................................................…...............……

..............................................................................………....................................................................…..........…...............……
¨ŠÉ°º ..........ª..´œ...š....ɸ ..............œ......µ....¥......….......Á.—..º°...œ...............................Ÿ..¼o…..°....¦..´...‹..µÎ.…œ°..Š...... ¡.«. ...........…….......
¨ŠºÉ° .........................œ...µ..¥...„........................... Ÿ…o¼ ° ‹Îµœ°Š
¨ŠºÉ° ........................................................... Ÿ¼o­°­ªœ

(………………………………………)

­µÎ ®¦´ ¡œ´„ŠµœÁ‹oµ®œµo šÉ¸

Ò) ¦µ‡µž¦³Á¤œ· šœ» š¦¡´ ¥.r .......................................………........……………...................………….µš..........…….…….............…..............­˜µŠ‡r
Ó) ̜—šÉ—¸ œ· Ä®¤n¦³ªµŠ...................……....................Á¨…šÉ—¸ œ· ..........…....………….......……..........®œoµ­Îµ¦ª‹....................……………...............

̜—šÉ¸—œ· Á¨…š.ɸ .......................……................….....Á¨¤n .................………….......................……..®œµo …………………..……….………………
‹µÎ œªœšÉ¸—·œ....................….........………......….......Ŧn...............……......……………....................Šµœ...............……....…........…...........˜µ¦µŠªµ
‡ŠÁ®¨º°.........................................………......….....Ŧn.............……..........……………..............….Šµœ.........…….........…..…..................˜µ¦µŠªµ
Ô) ŗ‹o —š³Á¥¸ œÂ¨oªÂ˜nªœ´ š.ɸ ..............…...............Á—º°œ...............................¡.«. ……………….

¨ŠºÉ° ....................................................................
( ................................................................. )
Á‹oµ¡œ´„Šµœš—¸É œ·

˜ª´ °¥µn Š®¤µ¥Á¨… ÔÒ ˜µ¤¦³Á¥¸ …o° ÓÚ (Õ) (š.—. Ò×)

´œš„¹ …o°˜„¨Šž¨°—‹µÎ œ°Š

š¸É—·œ
¦³ªµŠ.......………………..........................…..˜µÎ ¨...........……………………………..…………….............
Á¨…šÉ—¸ œ· ……………………®œoµ­Îµ¦ª‹......………...............°ÎµÁ£°..............…........……................................
̜—®¤µ¥Á¨…š…¸É …………………………….……….‹´Š®ª—´ ................................…….…...........................
š¸ªÉ µn „µ¦…………..….…………………………
ª´œš…ɸ ………Á—°º œ………….…….…¡.«. ……………

Á¨…ž¦³‹µÎ ˜ª´ ž¦³µœ

…µo ¡Á‹µo ..……….....œ...µ.¥...….......…Ÿ…o¼¦´…‹.µÎ..œ…°.Š........................………....... † †††† ††††† †† †
..……….....œ..µ..¥...„.......…Ÿ…¼o‹µÎ…œ.°..Š….........................………....... † †††† ††††† †† †

°µ¥» ................ že Á°ºÊ µ˜…· ………….…… ­´ µ˜·........................... ·—µ / ¤µ¦—µÉ°º ..........….….........................................
°¥n¼š¸É µo œ/®¤n¼ µo œ ...................... Á¨…šÉ¸ ................. ˜¦°„/Ž°¥ ....…….........….......... ™œœ ..........…….…………..®¤n¼šÉ¸ .....…...
˜Îµ¨/…ªŠ ...................... °ÎµÁ£°/Á…˜ ............................ ‹Š´ ®ª—´ ...…......………................®¤µ¥Á¨…Ú¦«´¡šr .….....................
…///°//ž//’///· //µ//–///˜//œ///Â//¨//³//Ä/®///™o//°o//¥//‡//ε//˜//°n/ …Å…—šo…兝´œ…š…¹„……°o ˜…„…¨Š…˜°n …Á‹…oµ¡…œ´„…Š…µœ…š¸É—…·œ……………………………………………………..
—///oª//¥/‡///ª//µ/¤//­///˜´ //¥//‹r //¦//·Š/ —´Š˜n°Åžœ¸Ê : -
…………š…¸É—…·œÂ…ž…¨Š…Á‡…¦Éº°…Š®…¤…µ¥……µo Š……œœ…¸Ê Â…¥„…¤…µ‹…µ„.Ã…Œ…œ—…Á¨……š……ɸ …….……………°Îµ…Á£…°………………………….Ã…—…¥……oµ¡..Á…‹oµ…œ…µ¥…„.…Ÿo¼‹…µÎ œ…°…ŠÅ…—o .
…‹µÎ œ…°…ŠÅ…ª„o …´ …œ…µ¥…….…Ÿ¦o¼…´ …‹µÎ …œ°…Š.˜…µ¤…­…´ …µ…‹µÎ …œ°…ŠŒ……´ ¨…Š…ªœ´ …šÉ¸…………Á…—°º …œ………….………………¡….«…………….Á¡…É°º …Áž…œ} ž..…¦³…„´œ…®…œ„ʸ …¼¥o º¤…ÁŠ…·œŽ…¹ÉŠ.
…Ÿ‹¼o …µÎ œ…°Š…„¼o¥…º¤…Ş…‹µ…„Ÿ…¼¦o ´…‹…圅°Š…Áž…œ} …‹Îµœ…ª…œ……………………..…………………µ…š (…….……………..………………………………)…´—…œ…ʅ¸ µo …¡Á.‹.…oµš…´ÊŠ­…°…Š …iµ¥…˜„…¨Š…„…´œ .
…Ä®…oš¸É—…·œ…ž…¨…ŠÁ‡…¦…ɺ°Š…®¤…µ…¥……oµŠ…œ.…œ…¸Ê¡oœ…‹…µ„…„µ…¦‹…µÎ œ…°…ŠÅ…žÃ…—…¥š…¸É¥´Š…¤·Å…—…o¤¸„…µ¦….ε…¦³…®…œÊ¸š…ɸ‹…圅°Š…Áž…}œž…¦…³„..´œ…Â…˜n°…¥…nµŠÄ…—…­…nªœ….
…Ì…œ—…š…—ɸ œ· …Á¨……š…ɸ…………………….…….….…….‡…Š‹…µÎ œ…°Š…Áž…}œ…ž¦…³„.…´œ®…œ…Äʸ œ…ªŠ…ÁŠ…œ· Á.—…·¤…°¥…¼n˜µ…¤Á…—¤· …ÁŠ…ɺ°œ…Å……Â…¨³………o°˜…„¨..Š…°…œºÉ …Ç Ä…®…Áo ž…}œÅ…ž˜…µ¤….
…­´……µ‹…圅°Š…Á—…·¤š…„» …ž¦…³„…µ¦…….……………………………………………….…………………………..…………………….
……………œ´ …š¹„………o°˜…„¨…Š…œ¸šÊ …µÎ Å…ª®o…œ…Š¹É Œ……´ …Á„ȝ…Å…ªo –…­.…µÎ œ…´„…Šµ…œš…—ɸ ·œ…š.…´ÊŠ­…°…Š …µi ¥…ŗ…˜o ¦…ª‹…—…¼´œ…š…¹„……o°˜…„.¨.…Š …¨…³Á……oµ…ċ……o°…‡ª…µ¤….
…˜¨…°—…Â…¨oª…‹Š¹…¨…Š¨…µ¥…¤º°…É°º…®…¦º°…¨Š.…¨µ…¥¡…·¤…¡rœ…Ê·ª…¤°º …Ū…Áo ž…}œ®…¨…´„“…µœ…˜…n°®…œ…oµ¡…¥µ…œÂ.…¨³…Á‹…oµ¡…œ…´„Š…µœ…šÉ¸—…·œ……..…………………….

…………………………………………………………………………………………………………….…………………………………………………………..………………………¨¨ŠŠ………°ÉºÉ°º ……………………………..……………………………………………œœ……µµ.………¥¥………„…………….. ……………………………………………………………ŸŸ‹o¼¼o¦………´µÎ œ‹………°Îµœ…..Š..……°.Š.………………………………………………………………...
………………………………….……………………………¨Š…ºÉ°……………………………….…………………………………¡¥…µœ……..…………………….
……………………………………………………….………¨Š…É°º ………….………………………………………………………¡¥…µœ…..……………………….
……………´œ…š„¹………o°˜…„¨…Š…œÅʸ …—oš…ε˜.…n°®…œ…oµ ……………………………………….…………………………..…………………….
……………………………………………………….………¨Š…ºÉ°………….………………………………………………………Á‹µo…¡…œ„´ ..Š…µœ…š…—¸É ·œ……………….
………………………………….…………………………………ž…¦³…š´ …˜…¦µ…˜Îµ.Â…®…œnŠ…Áž…}œ­…µÎ …‡´…………..…………………….

……………………………………………………….……………….…………………………………..……………………….

……………………………………………………….……………….…………………………………..……………………….

………………………………….……………………………………………….…………………………..…………………….

……………………………………………………….……………….…………………………………..……………………….

………………………………….……………………………………………….…………………………..…………………….

˜ª´ °¥nµŠ®¤µ¥Á¨… ÔÒ ˜µ¤¦³Á¸¥…°o ÓÚ (Õ)
­µ¦´‹—š³Á¸¥œ

ÁœºÊ°š¸—É ·œ ÁœÊ°º šÉ¸—œ· ¦³ªµŠ Á‹oµ¡œ´„Šµœš¸—É ·œ
Á¨…š¸É—·œ ¨Š¨µ¥¤º°É°º
‹—š³Á¥¸ œ ž¦³Á£š„µ¦ Ÿ¼Äo ®o­´µ Ÿ¦o¼ ´ ­´ µ ˜µ¤­´ µ ‡ŠÁ®¨º° ̜—šÉ—¸ ·œÄ®¤n ž¦³š´˜¦µ
ªœ´ Á—°º œ že ‹—š³Á¥¸ œ œµ¥ „. œµ¥ ….
Ŧn Šµœ ˜µ¦µŠ Ŧn Šµœ ˜µ¦µŠ - (¨ŠºÉ°) œµ¥ ¡.
œµ¥ …. Ÿo¦¼ ´ ‹Îµœ°Š ªµ ªµ ªœ´ š…ɸ ……………..
Ÿ¦o¼ ´ ‹Îµœ°Š Á—°º œ……………….
ª´œš¸É…………. ‹Îµœ°Š œµ¥ „. Ò- - --- ¡.«. ………………..
Á—°º œ………… (‡¦°‹Îµœ°Š) (¨Šº°É )……………..
¡.«. ………… „µ¦‹Îµœ°Š¥Š´ ‡Š¤°¸ ¥¼˜n µ¤­´ µ‹µÎ œ°Š
Œ´¨Šª´œš…ɸ ….Á—°º œ……………¡.«…..

ª´œšÉ¸…………. ž¨°—‹µÎ œ°Š Ò-- - - - - (¨Šº°É )……………..
Á—º°œ…………
¡.«. ………… šÉ¸—·œÂž¨Šœ¸Ê¡oœ‹µ„„µ¦‹Îµœ°Š˜µ¤­´µ‹Îµœ°Š

Œ´¨Šªœ´ š…¸É …..Á—º°œ……………….¡.«. ….
˜µ¤œ´ š¹„…°o ˜„¨Šž¨°—‹Îµœ°Š ¨Šª´œš…¸É ….
Á—°º œ………………¡.«. …

˜´ª°¥nµŠ®¤µ¥Á¨… ÔÓ ˜µ¤¦³Á¥¸ …o° ÔØ (Ò) † š¸Éµo œ (š.—. Ò)

† š¸­É ªœ/Ŧn
† šœÉ¸ µ
‡Îµ…°‹—š³Á¥¸ œ­š· ›Â· ¨³œ·˜·„¦¦¤ † šÉ¸ ..............
¨³„µ¦­°­ªœ­š· ›Ä· œšÉ—¸ ·œ ž¦³Á£š ...…..µ.¥..¦..³..®...ª.…nµŠ‹…µÎ œ…°…Š ……......... † œ°„Á…˜
˜µÎ ®œnŠšÉ—¸ ·œ ˜µ¤‡µÎ ­Š´É …(¦³…» …É°º Ÿ…¼¤o ¸°…µÎ œ…µ‹…°°…„‡…ε­…Ɋ´ ). (˜µ¤®œŠ´ ­°º ….š…¸É ./…¨Šª´œš…¸É ……..….) † ĜÁ…˜
¦³ªµŠ..........................................…..........................................……..˜Îµ¨.........................................……......….....................................................…..

Á¨…šÉ¸—·œ..................................................................………............…°µÎ Á£°.....................................…...........................................……....................…..

®œµo ­Îµ¦ª‹...................................................................……..............‹Š´ ®ª—´ ...........................................................................................……........…….
̜—š—ɸ ·œ
Á¨…š.¸É .............................................................……..........................Á¨¤n ..........………..………........................®œµo ......………….…..…...……......…..
‹ÎµœªœšÉ¸—œ· .................Ò...................…....................Ŧn.....………………- ……….....................Šµœ.................…………- …...….................…....˜µ¦µŠªµ

Ò. …oµ¡Á‹µo Ÿo¤¼ œ¸ µ¤˜n°Åžœ¸Ê ¤¸‡ªµ¤ž¦³­Š‡r…°‹—š³Á¥¸ œ­š· ›Â· ¨³œ·˜„· ¦¦¤Á„¥¸É ª„´°­´Š®µ¦·¤š¦¡´ ¥šr „ɸ ¨µn ª…oµŠœœÊ¸ ¨³Å—žo ’·µ–˜œÂ¨oª
…°Ä®o™°o ¥‡Îµ—oª¥‡ªµ¤­˜´ ¥r‹¦·Š ™oµ…oµ¡Á‹oµÄ®o™o°¥‡ÎµÅ¤Án ž}œ‡ªµ¤‹¦Š· Ä®očo™o°¥‡Îµœ¸¥Ê ´œ…µo ¡Á‹oµÄœšµŠ‡—°¸ µµÅ—o
Á¨…ž¦³‹Îµ˜ª´ ž¦³µœ
Ó. …oµ¡Á‹µo .........œ...µ..¥....„...............……..................... † †† † Ÿ¼o ......…...µ.¥.……….....….....…..
†††† †††††

°µ¥» .............................. že ­´µ˜· ..............................…………............. ·—µ / ¤µ¦—µÉ°º ........................................................................…......…..
† í— † ®¤oµ¥ † ‡¼­n ¤¦­É°º .................………….......…...………............…............…...........……
°¥nš¼ ¸É oµœ/®¤¼n µo œ ..................……....... Á¨…šÉ¸ ........................ ˜¦°„/Ž°¥ ...........…...…................. ™œœ ..….......……..….....….....®¤¼nšÉ¸ ..…......……
˜Îµ¨/…ªŠ .....................….............°ÎµÁ£°/Á…˜ ..............…….................. ‹Š´ ®ª—´ ..........….…...........…........®¤µ¥Á¨…Ú¦«¡´ šr .............…............…
Á¨…ž¦³‹µÎ ˜´ªž¦³µœ
Ô. …µo ¡Á‹µo ..............œ...µ.¥...….…. …............................... † †† † Ÿo¼ ...Ž...ʺ°....…............…..……..
†††† †††††

°µ¥» .......Õ...Ñ.................... že ­´µ˜· .....…....................................... —· µ / ¤µ¦—µº°É ...............………............................…................…...........…..…
† í— † ®¤oµ¥ † ‡­n¼ ¤¦­°ºÉ .....................……....................­´µ˜· ………..…...…….........……
°¥¼nš¸É oµœ/®¤n¼ oµœ ................................ Á¨…šÉ¸ .....……............ ˜¦°„/Ž°¥ ..................……............. ™œœ ................……...…..........®¤šn¼ ¸É ...…......…...

˜µÎ ¨/…ªŠ ................................. °ÎµÁ£°/Á…˜ ................……..................‹´Š®ª—´ ......……......….…..............®¤µ¥Á¨…Ú¦«´¡šr ..............….......…....
Õ. …oµ¡Á‹µo …°Â­—Š¦µ‡µš¦¡´ ¥rš…ɸ °šµÎ œ·˜·„¦¦¤œ¸ÊÁžœ} ÁŠ·œ .............Ö....Ñ..Ñ...,.Ñ..Ñ…Ñ….......................... µš ....…….......…-............­˜µŠ‡r
(®oµÂ­œµš™oªœ)
Ö. …oµ¡Á‹µo …°¦´¦°Šªnµ

(Ò) …µo ¡Á‹µo ŤÅn —o¦´ ðœÂšœ®¦º°Á¡Éº°ž¦³Ã¥œr„n »‡‡¨˜nµŠ—µo ª

(Ó) ¦.….(µ.¦.‡.…³.µ..š.….».¦.°Éº.…´¡..Ÿ¥..…¼o¤.šr ..¸°¸ÂÉ.….ε.­.œ.…—..µ.Š‹.….Å.°.ª.…°.oÄ.„.œ..‡.…Õ.µÎ..­....ÁɊ´….ž)..œ}...¦.….µ.µ.‡.¥.µ.š.š.°..¸ÂÉ .—.š.˜.…o‹¨¦µ…·Š—š…ɸ—.·œ...¦..³..®...ª..µn..Š..‹..µÎ..œ...°..Š..Á.¡...°Éº.....µÎ .¦...³..£..µ..¬...…¸ ....…....…....…......Ã..—..¥..¤...¸„..µ..¦..‹..µÎ..œ..…°Š.˜..·—...Å..ž...—..oª..¥....……
(Ô)
(Õ) ..............................................................................……….................................................................................…...............……

(˜¨¨µŠŠ¤®°ºÉºÉ°œ....Š´....­.....º°.....…..ª.....œ´.…....š...œ....š.¸É....µ...…ɸ..¥........../..…..…............…............¨......Š..Á..—ª....œ´.º°.....œš......…ɸ ............…............…............…....Ÿ.Ÿ...)o¼…¼o…..°°...…..Žµ..¥°ºÊ.....…........ ¡.«. ...........…….......
¨ŠºÉ° ........................................................... Ÿ­¼o °­ªœ

(………………………………………)

­Îµ®¦´ ¡œ´„ŠµœÁ‹oµ®œµo šÉ¸

Ò) ¦µ‡µž¦³Á¤œ· šœ» š¦´¡¥.r .......................................………........……………...................………….µš..........…….…….............…..............­˜µŠ‡r
Ó) ̜—š¸É—œ· Ä®¤n¦³ªµŠ...................……....................Á¨…š¸É—·œ..........…....………….......……..........®œoµ­Îµ¦ª‹....................……………...............

̜—š¸É—·œÁ¨…š.ɸ .......................……................….....Á¨n¤.................………….......................……..®œµo …………………..……….………………
‹µÎ œªœšÉ—¸ ·œ....................….........………......….......Ŧn...............……......……………....................Šµœ...............……....…........…...........˜µ¦µŠªµ
‡ŠÁ®¨º°.........................................………......….....Ŧn.............……..........……………..................Šµœ.........…….........…..….................˜µ¦µŠªµ
Ô) ŗ‹o —š³Á¸¥œÂ¨ªo ˜nªœ´ š.¸É ..............…...............Á—º°œ...............................¡.«. ……………….

¨Š°ºÉ ..........................................................
( ........................................................ )

Á‹µo ¡œ„´ Šµœš¸É—·œ

˜´ª°¥nµŠ®¤µ¥Á¨… ÔÓ ˜µ¤¦³Á¥¸ …o° ÔØ(Ò) (š.—. Ú)

‡Îµ…°...…..µ.¥..¦..³..®..ª..nµ..Š.‹..µÎ..œ..°..Š..˜. µ¤‡µÎ ­ŠÉ´ (…¦³…»…°ºÉ Ÿ..o¤¼ …°¸ 兜µ…‹°…°„…‡Îµ…­´ŠÉ .)

(˜µ¤®œ´Š­º°……....š…¸É . /.….¨Šªœ´ š…¸É …………)

Œ´ š.ɸ .............................

šÉ¸—œ·
¦³ªµŠ.........................................................………....................˜Îµ¨.......……….…..…................................................
Á¨…š.¸É ......................................®œoµ­Îµ¦ª‹.........................…………..................°ÎµÁ£°.…………….........................…..
̜—®¤µ¥Á¨…š.¸É ...........................................……………...............‹´Š®ª—´ .....................…………………………..…..

ªœ´ šÉ¸.......…….......Á—º°œ..............………................¡.«.........….........

Á¨…ž¦³‹µÎ ˜ª´ ž¦³µœ

…oµ¡Á‹oµ....................œ...µ.¥...…...................………………………….…….……† †††† ††††† †† †
..............................................………………………….…….……† †††† ††††† †† †

°µ¥.» ......Õ...Ñ........že ÁÊº°µ˜·...........……..............­´µ˜·.........………….............—· µ/¤µ¦—µÉº°..............……….............................
°¥¼nšÉ¸µo œ/®¤¼n µo œ...................................Á¨…š.ɸ .……................˜¦°„/Ž°¥……………………™œœ………………....®¤¼nš¸É...........
˜µÎ ¨/…ªŠ.………...............°ÎµÁ£°/Á…˜......………...............‹Š´ ®ª—´ ...………….................®¤µ¥Á¨…Ú¦«´¡šr......……………..
…°¥Éœº ‡µÎ …°˜°n Á‹oµ¡œ´„Šµœš¸É—·œ‹´Š®ª´—...........................…….........................—oª¥‡ªµ¤­˜´ ¥r‹¦Š· ªµn :-

…o° Ò. —ªo ¥..š...¸É—..·œ...Â..ž...¨..Š..Á.‡...¦…ºÉ°Š…®…¤µ…¥—…´Š„…¨nµ…ª……oµŠ…œ…œ…¸Ê ¤.¸...°ºÉ ...œ...µ..¥...„....Á.ž...}œ..Ÿ...¼™o ..º°..„...¦..¦..¤..­...š·...›..Í·....´—..œ...¸Ê….(.¦..…³....…»..ºÉ°..….Ÿ..¤o¼ .….°¸ ..µÎ .…œ...µ.…‹..°.….°..„.….‡..ε.….­..É´Š.….).....
.Å..—..o¤...‡¸ ..µÎ..­..ŠÉ´..…...µ.¥..š...°...—..˜..¨...µ..—..¦..³..®...ª..µn..Š..‹..µÎ..œ..°...Š...Á.¡...°ºÉ ....ε..¦…³£…µ…¬¸ …¨…³……oµ¡...Á.‹..µo...œ...µ..¥...…...Á.ž...}œ...Ÿ..o¼Ž...ʺ°..Å..—...oÃ..—..¥..¤...„¸ ..µ..¦..‹..ε..œ...°..Š..˜..·—...Å..ž..—...ªo..¥....¦..µ..¥..¨..³...Á.°..¸¥..—.....
.ž..¦..µ..„..’...˜..µ..¤...®...œ..´Š..­...°º..…....…....…......š...…¸É....….....…...../.…....…....…...…. ¨…Šª…´œ…š…ɸ ………………....…....š...ÉŸ ..—..o¥..ºÉœ...¤...µ.¡...¦..o°...¤..œ...ʸ..Â..¨...³..…..oµ..¡...Á.‹..oµ..Å..—..o...ε.¦...³..¦..µ.‡...µ..š..¸É—...œ· ....
.‡..¦.....™..oª..œ...Â..¨...oª......................................................…………………………........................................................................................

..........................................................................………………........................................................................................................

..........................................................................…………………………........................................................................................

..........................................................................…………………………........................................................................................

..........................................................................………………………….........................................................................…............

..........................................................................………………………….........................................................................…............
…o° Ó. Œ³œœ´Ê …°Ä®Áo ‹µo ¡œ´„Šµœš—ɸ œ· ....Ã...ž..¦..—...—..ε..Á.œ...·œ...„…µ¦..‹..—..š...³..Á....¥¸..œ...…..µ..¥..š...¸É—..·œ...Ä..®...oÂ..„..…n...oµ.¡...Á.‹...µo .—...oª..¥...š...ʊ´ .œ...ʸ.…...µo .¡...Á.‹..oµ..¥..°.…¤Á…­¥¸ ..…

‡...µn ..›..¦..¦..¤...Á.œ..¸¥...¤..˜..µ..¤...¦..³..Á....¸¥.....................................…………………………........................................................................................

..........................................................................………………........................................................................................................

..........................................................................…………………………........................................................................................

..........................................................................…………………………........................................................................................

..........................................................................………………………….........................................................................…............

……................……œ..µ..¥...…................…..........Ÿ…¼o °
................…….....….…........…..................¡¥µœ
..................……….........……......................¡¥µœ

˜´ª°¥nµŠ®¤µ¥Á¨… ÔÓ ˜µ¤¦³Á¸¥…°o ÔØ (Ò)
­µ¦´ ‹—š³Á¸¥œ

ÁœÊ°º š—ɸ ·œ ÁœºÊ°šÉ—¸ œ· ¦³ªµŠ Á‹oµ¡œ´„Šµœš¸—É ·œ
Á¨…šÉ¸—·œ ¨Š¨µ¥¤º°ºÉ°
‹—š³Á¸¥œ ž¦³Á£š„µ¦ Ÿo¼Ä®o­´ µ Ÿ¦o¼ ´­´µ ˜µ¤­´ µ ‡ŠÁ®¨°º ̜—šÉ—¸ ·œÄ®¤n ž¦³š´ ˜¦µ
ª´œ Á—°º œ že ‹—š³Á¸¥œ œµ¥ ….
Ŧn Šµœ ˜µ¦µŠ Ŧn Šµœ ˜µ¦µŠ - ¨Š°Éº …………….
ªµ ªµ

ª´œš…ɸ ………. …µ¥¦³®ªnµŠ‹Îµœ°Š œµ¥ „. Ò- - ---
Á—º°œ………… ˜µ¤‡Îµ­Š´É (…¦³…» …É°º Ÿ…¤o¼ ¸
…°µÎ …œµ…‹°…°„…‡µÎ …­´ÉŠ…)
¡.«. ……….…
(˜µ¤®œŠ´ ­°º ……..
š…ɸ ……/………..
¨Šª´œš…¸É ……….)

‹—´ šµÎ ×¥

š¸Éž¦¹„¬µ

œµŠ­µªœ´œšœµ ¡´•œª·¨¼ ¥r Ÿ¼o°µÎ œª¥„µ¦­ªn œ¤µ˜¦“µœ„µ¦‹—š³Á¸¥œ­·š›·Â¨³œ·˜„· ¦¦¤

¦ª¦ª¤…°o ¤¼¨

œµŠ­µªœ´¥œµ Á¨·«µ¦¤ª¸ Š«r œ´„ª·µ„µ¦š¸É—·œµÎ œµ„µ¦
œµŠ­µ¥ œ ­¤¼¦–r
œµ¥­¤£¡ «¦¸£„´ —¸ „¨»¤n ¡•´ œµ¦³„µ¦‹—š³Á¸¥œ­š· ›Â· ¨³œ·˜„· ¦¦¤

­µÎ œ„´ ¤µ˜¦“µœ„µ¦š³Á¸¥œšÉ¸—·œ
œ´„ªÁ· ‡¦µ³®rœÃ¥µ¥Â¨³ÂŸœµÎ œµ„µ¦

„¨n»¤¡´•œµ¦³„µ¦‹—š³Á¥¸ œ­š· ›·Â¨³œ·˜·„¦¦¤

­µÎ œ„´ ¤µ˜¦“µœ„µ¦š³Á¸¥œšÉ—¸ ·œ
œ„´ ª·µ„µ¦šÉ¸—·œµÎ œµ„µ¦

„¨»n¤¡´•œµ¦³„µ¦‹—š³Á¥¸ œ­š· ›·Â¨³œ˜· „· ¦¦¤

­µÎ œ„´ ¤µ˜¦“µœ„µ¦š³Á¥¸ œš¸—É ·œ