84
12.
Ƚɚɪɚɧɬɢɣɧɵɣ
ɬɚɥɨɧ
/
Ɏɨɪɦɭɥɹɪ
ɤɨɧɬɪɨɥɹ
ɩɪɢ
ɩɨɤɭɩɤɟ
Ɏɚɦɢɥɢɹ
:
________________________________________________
Ⱥɞɪɟɫ
:
________________________________________________
ɉɨɱɬɨɜɵɣ
ɢɧɞɟɤɫ
:
________________________________________________
Ƚɨɪɨɞ
:
________________________________________________
Ɍɟɥɟɮɨɧ
(
ɫ
ɤɨɞɨɦ
ɫɬɪɚɧɵ
,
ɝɨɪɨɞɚ
):
________________________________________________
ɗɥɟɤɬɪɨɧɧɚɹ
ɩɨɱɬɚ
:
________________________________________________
________________________________________________
Ⱥɜɬɨɦɨɛɢɥɶɧɨɟ
/
ɜɟɥɨɫɢɩɟɞɧɨɟ
ɞɟɬɫɤɨɟ
ɫɢɞɟɧɶɟ
:
________________________________________________
ɇɨɦɟɪ
ɚɪɬɢɤɭɥɚ
:
________________________________________________
ɐɜɟɬ
ɦɚɬɟɪɢɚɥɚ
(
ɭɡɨɪ
):
________________________________________________
Ʉɪɟɩɥɟɧɢɟ
:
________________________________________________
