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- 4. §º§Ñ§Ò§Ý§à§ß §á§à§Ó§Ö§ã§ä§Ü§Ú §Ú §á§â§à§ä§à§Ü§à§Ý§Ñ §Ó §ã§à§à§ä§Ó§Ö§ä§ã§ä§Ó§Ú§Ú §ã§à §ã§ä§Ñ§ß§Õ§Ñ§â§ä§à§Þ §ä§Ñ§Û§Þ- §Þ§Ö§ß§Ö§Õ§Ø§Þ§Ö§ß§ä§Ñ §µ§´§£§¦§²§¨§¥§¡§À §±§â§Ö§Õ§ã§Ö§Õ§Ñ§ä§Ö§Ý§î ______________________________ (§Õ§à§Ý§Ø§ß§à§ã§ä§î) ____________ /_________________ ?___?___________ 20___§Ô. §±§²§°§´§°§¬§°§ §³§°§£§¦§»§¡§¯§ª§Á §¥§Ñ§ä§Ñ §ã§à§Ó§Ö§ë§Ñ§ß§Ú§ñ: §£§â§Ö§Þ§ñ §ã§à§Ó§Ö§ë§Ñ§ß§Ú§ñ: §®§Ö§ã§ä§à §á§â§à§Ó§Ö§Õ§Ö§ß§Ú§ñ: §µ§é§Ñ§ã§ä§ß§Ú§Ü§Ú: ¡ì1. §°§á§â§Ö§Õ§Ö§Ý§Ú§ä§î §á§Ö§â§Ö§ç§à§Õ§ß§í§Û §á§Ö§â§Ú§à§Õ §Ü §ß§à§Ó§à§Û §ã§ä§â§å§Ü§ä§å§â§Ö §²§Ö§ê§Ö§ß§Ú§Ö §±§à§â§å§é§Ö§ß§Ú§Ö §°§ä§Ó§Ö§ä§ã§ä§Ó§Ö§ß§ß§í§Û §³§à§à§ä§Ó§Ö§ä§ã§ä§Ó§Ö§ß§ß§í§Û §³§â§à§Ü ¡ì2. §°§Ò§Ù§à§â §Ü§Ó§Ñ§â§ä§Ñ§Ý§î§ß§í§ç §á§Ý§Ñ§ß§à§Ó §®§ª§´ §²§Ö§ê§Ö§ß§Ú§Ö §±§à§â§å§é§Ö§ß§Ú§Ö §°§ä§Ó§Ö§ä§ã§ä§Ó§Ö§ß§ß§í§Û §³§à§à§ä§Ó§Ö§ä§ã§ä§Ó§Ö§ß§ß§í§Û §³§â§à§Ü ¡ì3. §²§Ñ§ã§ã§Þ§à§ä§â§Ö§ß§Ú§Ö §Ü§Ñ§Û§Õ§Ù§Ö§ß-§á§â§Ö§Õ§Ý§à§Ø§Ö§ß§Ú§Û, §Ü§à§Ý§Ý§Ú§Ù§Ú§Û §Ú §â§Ú§ã§Ü§à§Ó §²§Ö§ê§Ö§ß§Ú§Ö §±§à§â§å§é§Ö§ß§Ú§Ö §°§ä§Ó§Ö§ä§ã§ä§Ó§Ö§ß§ß§í§Û §³§à§à§ä§Ó§Ö§ä§ã§ä§Ó§Ö§ß§ß§í§Û §³§â§à§Ü ¡ì4. §±§â§Ú§ß§ñ§ä§Ú§Ö §ê§Ñ§Ò§Ý§à§ß§à§Ó §á§Ý§Ñ§ß§Ñ, §á§à§Ó§Ö§ã§ä§Ü§Ú, §á§â§à§ä§à§Ü§à§Ý§Ñ §²§Ö§ê§Ö§ß§Ú§Ö §±§à§â§å§é§Ö§ß§Ú§Ö §°§ä§Ó§Ö§ä§ã§ä§Ó§Ö§ß§ß§í§Û §³§à§à§ä§Ó§Ö§ä§ã§ä§Ó§Ö§ß§ß§í§Û §³§â§à§Ü §ª§´§°§¤§° §á§à §á§à§Ó§Ö§ã§ä§Ü§Ö §Ù§Ñ§ã§Ö§Õ§Ñ§ß§Ú§ñ ¡í §Ó§à§á§â§à§ã§Ñ §±§Ý§Ñ§ß§Ú§â§å§Ö§Þ§à§Ö §Ó§â§Ö§Þ§ñ §à§Ò§ã§å§Ø§Õ§Ö§ß§Ú§ñ §¶§Ñ§Ü§ä§Ú§é§Ö§ã§Ü§à§Ö §Ó§â§Ö§Þ§ñ §à§Ò§ã§å§Ø§Õ§Ö§ß§Ú§ñ ¡ì1. ¡ì2. ¡ì3. ¡ì4. §ª§´§°§¤§°: §³§Ö§Ü§â§Ö§ä§Ñ§â§î §ã§à§Ó§Ö§ë§Ñ§ß§Ú§ñ _______________/§¶§ª§° §´§Ö§Ý§Ö§æ§à§ß: 254-XX-XX, §Ó§ß.: (XX) XXX