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Text File  |  1980-01-01  |  2KB  |  29 lines
  1.  
  2.  
  3.                               ╖╛¿ñ╛¡í╝·╕í±«╖╛¿Ñ╛·¿ó║ñ
  4.                                    ú╜¡╜í±┤┤╜í╛¡
  5.  
  6. ╣¡√╛¼≤· ╣╖⌠ ░┴¡í╗±«░≥⌐º║«: ______________________________________________
  7.      º⌡· ____________________________________________________________
  8. ¼≤·╡°· ________________________________________________________________
  9. └┤⌡║ñ ______________________ ╢±½ _______________ º≥«┬ú⌐ ______________
  10. ┬¼╢╜º±«¼≤·ú╢≥ª¬╜ѱí (    ) ________________ ¼≤·«╛√¡ (    ) ________________
  11. Ñ╛≡¡╕¡└ñ≤¡¼≤·─⌐√╗±«¼±ñ╣┤÷⌐Ñ╛í ªú╖: $ _____________.
  12. ___________________________________________________________________
  13.   └╖í╖╛≡⌐±«       ╖╛¿í╛¡¬·╛ñ┼ ¼≤·├º√Ñ·╛¿                      Ñ╛≡¡╕¡¼≤·Ñ·╛¿
  14. ___________________________________________________________________
  15.    1. .............................................................
  16.    2. .............................................................
  17.    3. .............................................................
  18.    4. .............................................................
  19.    5. .............................................................
  20. ___________________________________________________________________
  21.  
  22.                               ╗╕┤└ñ≤¡¼≤·Ñ·╛¿¼±ñ╣┤÷⌐├¡»≤¡≤√: ________________
  23.                              └ñ≤¡¼≤·└╣╖⌡║Ñ·╛¿¼±ñ╣┤÷⌐├¡»≤¡≤√: ________________ 
  24.  
  25.               ╕±¡¼≤ __________ └⌐⌡║¡ ____________________ »≤ __________
  26.  
  27.               _________________________   _________________________
  28.                      ¡╛¿ú±ñ                        ░°√╖╛¿ñ╛¡
  29.