(ķąčģåķīāąķčå īšćąķčēąöčč)
"__________"_______________20__ć. N ____________________
Źīģó ____________________________________________________________________
(äīėęķīńņü, Ō.Č.Ī.)
_________________________________________________________________________
(ķąčģåķīāąķčå ļīäšąēäåėåķč’ īšćąķčēąöčč)
Ā ńīīņāåņńņāčč ńī ńņąņüåé(’ģč) __________________________________________
_________________________________________________________________________
(ķąčģåķīāąķčå ķīšģąņčāķīćī ļšąāīāīćī ąźņą īį īõšąķå ņšóäą)
ļšåäėąćąž óńņšąķčņü ńėåäóžłčå ķąšóųåķč’:
|N |Ļåšå÷åķü āū’āėåķķūõ ķąšóųåķčé |Ńšīźč óńņšąķåķč’ |Īņģåņźč īį |
|ļ/ļ|ņšåįīāąķčé īõšąķū ņšóäą | |óńņšąķåķčč |
|||||
|1 | 2 | 3 | 4 |
|||||
|||||
|||||
|||||
|||||
|||||
Ī āūļīėķåķčč ķąńņī’łåćī ļšåäļčńąķč’ ļšīųó ńīīįłčņü äī ___________________
(äąņą)
ļčńüģåķķī (ļī ņåėåōīķó)__________________________________________________
Ļšåäļčńąķčå āūäąė: ______________________________ _______________________
(ļīäļčńü, äąņą) (Ō.Č.Ī., äīėęķīńņü)
Ļšåäļčńąķčå ļīėó÷čė: ____________________________ _______________________
(ļīäļčńü, äąņą) (Ō.Č.Ī., äīėęķīńņü)
Źīķņšīėü óńņšąķåķč’ ķąšóųåķčé ļšīāåė: ___________________________________
(Ō.Č.Ī., äīėęķīńņü)
_________________________________________________________________________
(ļīäļčńü, äąņą)