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  1.  
  2.                                                      ö«α¼á æâ-2
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  4.                                               ä¿αÑ¬Γ«απ ÇÄçÆ
  5.                                             ö¿α¼á "îÇæÆÇè-êìöÄ"
  6.                                             ú-¡π àú«α«óπ  Ç.Ç.
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  12.      Åα«Φπ éáß íѺ󫺼Ѻñ¡« ºáαÑú¿ßΓα¿α«óáΓ∞ ¼Ñ¡∩ ó «º¡á¬«¼¿Γѽ∞-
  13. ¡δσ  µÑ½∩σ  ó  ¬áτÑßΓóÑ  áí¿Γπα¿Ñ¡Γá  âèÆæ æêÆàè. Äí∩ºπεß∞ ¡Ñ ¿ß-
  14. »«½∞º«óáΓ∞  óδñѽѡ¡δÑ éἿ  αÑßπαßδ  ñ½∩ «Γ»αá󬿠( »α¿Ñ¼á ) ß«-
  15. «íΘÑ¡¿⌐ ºá »αÑñѽδ âèÆæ æêÆàè, á ΓᬪѠ󠿡δσ µÑ½∩σ, »α«Γ¿ó«αÑτá-
  16. Θ¿σ µÑ½∩¼ ¿ »αáó¿½á¼ αáí«Γδ áí¿Γπα¿Ñ¡Γá âèÆæ æêÆàè.
  17.      é ß½πτáÑ ¡áαπΦÑ¡¿∩ »α¿¡∩Γδσ ¡á ßÑí∩ «í∩ºáΓѽ∞ßΓó úáαá¡Γ¿απε
  18. «»½áΓπ  ºá  Σá¬Γ¿τÑ߬¿  »«ΓαÑí½Ñ¡¡δÑ αÑßπαßδ »« µÑ¡á¼ ¿ πß½«ó¿∩¼
  19. ñÑ⌐ßΓóπεΘÑú« ó âèÆæ æêÆàè »αÑ⌐߬παá¡Γá. Ä ßÑíÑ ß««íΘáε:
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  21.      öἿ½¿∩____________________________________________________
  22. ê¼∩ __________________________ ÄΓτÑßΓó« ________________________
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  24. Åáß»«αΓ ßÑα¿∩___________ ¡«¼Ñα________________________ñáΓá óδñá-
  25. τ¿_____________________ ¬Ñ¼ óδñá¡ ______________________________
  26. ________________________________________________________________
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  28.      Å«τΓ«óδ⌐ áñαÑß ß ¿¡ñѬ߫¼: ________________________________
  29. ________________________________________________________________
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  31.      ÆѽÑΣ«¡ _________________________ ÆѽÑΣá¬ß_________________
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  33.      ï¿µÑ¡º¿∩ âèÆæ æêÆàè CÑα¿∩________ ì«¼Ñα____________________
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  38.        äáΓá ___________                     _________________
  39.                                                ( »«ñ»¿ß∞ ) 
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