Ìèíçäðàâ ÐÔ: Ïðèêàç îò 26.03.2002 N 91
Óòâåðæäåí 26.03.2002
Î ÂÍÅÑÅÍÈÈ ÈÇÌÅÍÅÍÈÉ È ÄÎÏÎËÍÅÍÈÉ Â ÏÐÈÊÀÇ ÌÈÍÇÄÐÀÂÀ ÐÎÑÑÈÈ È ÔÎÌÑ ÎÒ 16.05.2001 N 161/34
Ñêà÷àòü (9,6 Êá)

           ÌÈÍÈÑÒÅÐÑÒÂÎ ÇÄÐÀÂÎÎÕÐÀÍÅÍÈß ÐÎÑÑÈÉÑÊÎÉ ÔÅÄÅÐÀÖÈÈ

 

        ÔÅÄÅÐÀËÜÍÛÉ ÔÎÍÄ ÎÁßÇÀÒÅËÜÍÎÃÎ ÌÅÄÈÖÈÍÑÊÎÃÎ ÑÒÐÀÕÎÂÀÍÈß

 

                                 ÏÐÈÊÀÇ

 

                            26 ìàðòà 2002 ã.

 

                                N 91/16

 

               Î ÂÍÅÑÅÍÈÈ ÈÇÌÅÍÅÍÈÉ È ÄÎÏÎËÍÅÍÈÉ Â ÏÐÈÊÀÇ

             ÌÈÍÇÄÐÀÂÀ ÐÎÑÑÈÈ È ÔÎÌÑ ÎÒ 16.05.2001 N 161/34

 

       ÏÐÈÊÀÇÛÂÀÅÌ:

       1. Âíåñòè èçìåíåíèÿ  â  ïðèêàç  Ìèíçäðàâà  Ðîññèè  è  ÔÎÌÑ  îò

   16.05.2001  N  161/34 "Îá îðãàíèçàöèè ìåäèöèíñêîé ïîìîùè íàñåëåíèþ

   ×å÷åíñêîé Ðåñïóáëèêè â ëå÷åáíûõ  ó÷ðåæäåíèÿõ  Þæíîãî  ôåäåðàëüíîãî

   îêðóãà":

       1.1. Ïóíêò  1  äîïîëíèòü  ïîäïóíêòîì  1.1.,  èçëîæèâ   åãî   â

   ñëåäóþùåé ðåäàêöèè:

       "1.1. Ââåñòè  ñ  1  àïðåëÿ  2002   ãîäà   â   ïîäâåäîìñòâåííûå

   ìåäèöèíñêèå   ó÷ðåæäåíèÿ  ôîðìó  ñòàòèñòè÷åñêîé  îò÷åòíîñòè  N  65

   (ïðèëîæåíèå)".

       1.2. Èçëîæèòü ïîäïóíêò 4.4. ïóíêòà 4 â ñëåäóþùåé ðåäàêöèè:

       "Îáåñïå÷èòü åæåêâàðòàëüíîå   ïðåäñòàâëåíèå    â    Äåïàðòàìåíò

   îðãàíèçàöèè  è  ðàçâèòèÿ ìåäèöèíñêîé ïîìîùè íàñåëåíèþ èíôîðìàöèè â

   ñîîòâåòñòâèè ñ îòðàñëåâîé ôîðìîé ñòàòèñòè÷åñêîé îò÷åòíîñòè N 65".

       1.3. Ïóíêò 6 èçëîæèòü â ñëåäóþùåé ðåäàêöèè:

       "6. Êîíòðîëü çà âûïîëíåíèåì íàñòîÿùåãî  ïðèêàçà  âîçëîæèòü  íà

   çàìåñòèòåëÿ    Ìèíèñòðà   çäðàâîîõðàíåíèÿ   Ðîññèéñêîé   Ôåäåðàöèè

   Â.Á.Êîðáóòà   è   çàìåñòèòåëÿ   äèðåêòîðà    Ôåäåðàëüíîãî    ôîíäà

   îáÿçàòåëüíîãî ìåäèöèíñêîãî ñòðàõîâàíèÿ Î.Â.Àíäðååâó".

       2. Êîíòðîëü çà âûïîëíåíèåì  íàñòîÿùåãî  ïðèêàçà  âîçëîæèòü  íà

   çàìåñòèòåëÿ    Ìèíèñòðà   çäðàâîîõðàíåíèÿ   Ðîññèéñêîé   Ôåäåðàöèè

   Â.Á.Êîðáóòà   è   çàìåñòèòåëÿ   äèðåêòîðà    Ôåäåðàëüíîãî    ôîíäà

   îáÿçàòåëüíîãî ìåäèöèíñêîãî ñòðàõîâàíèÿ Î.Â.Àíäðååâó.

 

                                              Ìèíèñòð çäðàâîîõðàíåíèÿ

                                                 Ðîññèéñêîé Ôåäåðàöèè

                                                         Þ.Ë.ØÅÂ×ÅÍÊÎ

 

                                          Äèðåêòîð Ôåäåðàëüíîãî ôîíäà

                                           îáÿçàòåëüíîãî ìåäèöèíñêîãî

                                                          ñòðàõîâàíèÿ

                                                          À.Ì.ÒÀÐÀÍÎÂ

 

 

 

 

                                                           Ïðèëîæåíèå

 

                                                           ÓÒÂÅÐÆÄÅÍÎ

                                                             ïðèêàçîì

                                              Ìèíçäðàâà Ðîññèè è ÔÎÌÑ

                                             îò 26.03.2002 ã. N 91/16

 

   ------------------------------------------------------------------

   |              ÎÒÐÀÑËÅÂÀß ÑÒÀÒÈÑÒÈ×ÅÑÊÀß ÎÒ×ÅÒÍÎÑÒÜ              |

   |----------------------------------------------------------------|

   |    ÊÎÍÔÈÄÅÍÖÈÀËÜÍÎÑÒÜ ÃÀÐÀÍÒÈÐÓÅÒÑß ÏÎËÓ×ÀÒÅËÅÌ ÈÍÔÎÐÌÀÖÈÈ     |

   ------------------------------------------------------------------

 

   ------------------------------------------------------------------

   |   ÎÒ×ÅÒ Î ÊÀÄÐÀÕ, ÑÅÒÈ È ÄÅßÒÅËÜÍÎÑÒÈ ÌÅÄÈÖÈÍÑÊÈÕ Ó×ÐÅÆÄÅÍÈÉ   |

   |  ×Å×ÅÍÑÊÎÉ ÐÅÑÏÓÁËÈÊÈ Â ÏÅÐÈÎÄ ÂÎÑÑÒÀÍÎÂËÅÍÈß ÇÄÐÀÂÎÎÕÐÀÍÅÍÈß  |

   |                   çà _______________ 20__ ã.                   |

   ------------------------------------------------------------------

 

   -----------------------------------------   ----------------------

   |   Ïðåäñòàâëÿþò:     |      Ñðîêè      |   |     Ôîðìà N 65     |

   |                     |  ïðåäñòàâëåíèÿ  |   ----------------------

   |---------------------+-----------------|          Óòâåðæäåíà

   |1. Ìèíçäðàâ ×å÷åíñêîé|  åæåêâàðòàëüíî  |           ïðèêàçîì

   |   Ðåñïóáëèêè:       |                 |      Ìèíçäðàâà Ðîññèè

   | - Ìèíçäðàâó Ðîññèè; | 10 ÷èñëà ïîñëå  |   îò 26.03.02 ã. N 91/16

   |                     |îò÷åòíîãî ïåðèîäà|   ----------------------

   |                     |                 |   |   åæåêâàðòàëüíàÿ   |

   |                     |                 |   ----------------------

   -----------------------------------------

 

                1. Ìèãðàöèîííûå õàðàêòåðèñòèêè íàñåëåíèÿ

 

   ------------------------------------------------------------------

   | Ðàéîíû è ãîðîäêè <*> |            ×èñëî áåæåíöåâ               |

   | ðàçìåùåíèÿ áåæåíöåâ  |                                         |

   |----------------------+-----------------------------------------|

   |                      |âñåãî|        â òîì ÷èñëå äåòåé          |

   |----------------------+-----+-----------------------------------|

   |                      |     |Äî 1 ãîäà|1-3 ãîäà|4-6 ëåò|7-17 ëåò|

   |----------------------+-----+---------+--------+-------+--------|

   |----------------------+-----+---------+--------+-------+--------|

   |----------------------+-----+---------+--------+-------+--------|

   |----------------------+-----+---------+--------+-------+--------|

   |----------------------+-----+---------+--------+-------+--------|

   |----------------------+-----+---------+--------+-------+--------|

   |----------------------+-----+---------+--------+-------+--------|

   |----------------------+-----+---------+--------+-------+--------|

   |Âñåãî:                |     |         |        |       |        |

   ------------------------------------------------------------------

 

       --------------------------------

       <*> Óêàçàòü äèñëîêàöèþ è íîìåðà ãîðîäêîâ.

 

         2. Ñâåäåíèÿ î ìåäèöèíñêîì ïåðñîíàëå (ôèçè÷åñêèå ëèöà)

 

   ------------------------------------------------------------------

   |     Ìåäèöèíñêèå êàäðû     |×èñëî çàíÿòûõ äîëæíîñòåé | ôèç. ëèöà|

   |---------------------------+-------------------------+----------|

   |×èñëî âðà÷åé âñåãî         |                         |          |

   |     â òîì ÷èñëå:          |                         |          |

   |---------------------------+-------------------------+----------|

   |     ïåäèàòðîâ             |                         |          |

   |---------------------------+-------------------------+----------|

   |     àêóøåðîâ - ãèíåêîëîãîâ|                         |          |

   |---------------------------+-------------------------+----------|

   |×èñëî ñðåäíåãî ìåäèöèíñêîãî|                         |          |

   |ïåðñîíàëà, â ò.÷. àêóøåðîê |                         |          |

   |---------------------------+-------------------------+----------|

   |×èñëî ïðî÷åãî ìåäèöèíñêîãî |                         |          |

   |ïåðñîíàëà                  |                         |          |

   ------------------------------------------------------------------

 

       ×èñëî ìåäèöèíñêèõ ôîðìèðîâàíèé - âñåãî ____,  â  ò.÷.  øòàòíûõ

   ____, âíåøòàòíûõ ____, â òîì ÷èñëå ÂÖÌÊ "Çàùèòà" - âñåãî ____.

       Çàäîëæåííîñòü ïî çàðàáîòíîé  ïëàòå  ìåäèöèíñêèì  ðàáîòíèêàì  -

   âñåãî _____ ìëí.  ðóá., â ò.÷. â ðàçðåçå ìóíèöèïàëüíûõ îáðàçîâàíèé

   ____ ìëí. ðóá.

 

 

         3. Äåÿòåëüíîñòü ìåäèöèíñêèõ ôîðìèðîâàíèé ÂÖÌÊ "Çàùèòà"

 

   ------------------------------------------------------------------

   |                          |        Ôîðìèðîâàíèÿ, ìåñòî èõ       |

   |                          |          ðàñïîëîæåíèÿ <*>           |

   |                          |-------------------------------------|

   |                          |ÏÌÃ |ÁÑÌÏ N 1|ÁÑÌÏ N 2|ÁÑÌÏ N 3|ÈÒÎÃÎ|

   |--------------------------+----+--------+--------+--------+-----|

   |            1             | 2  |   3    |   4    |   5    |  6  |

   |                          |    |        |        |        |     |

   |--------------------------+----+--------+--------+--------+-----|

   |Îêàçàíà ìåäèöèíñêàÿ ïîìîùü|    |        |        |        |     |

   |- âñåãî â òîì ÷èñëå:      |    |        |        |        |     |

   |--------------------------+----+--------+--------+--------+-----|

   |     âîåííîñëóæàùèì       |    |        |        |        |     |

   |--------------------------+----+--------+--------+--------+-----|

   |     äåòÿì                |    |        |        |        |     |

   |--------------------------+----+--------+--------+--------+-----|

   |Íàïðàâëåíî íà ñòàöèîíàðíîå|    |        |        |        |     |

   |ëå÷åíèå - âñåãî           |    |        |        |        |     |

   |â òîì ÷èñëå:              |    |        |        |        |     |

   |--------------------------+----+--------+--------+--------+-----|

   |     âîåííîñëóæàùèõ       |    |        |        |        |     |

   |--------------------------+----+--------+--------+--------+-----|

   |     äåòåé                |    |        |        |        |     |

   |--------------------------+----+--------+--------+--------+-----|

   |Ñòðóêòóðà çàáîëåâàíèé:    |    |        |        |        |     |

   |--------------------------+----+--------+--------+--------+-----|

   |     õèðóðãè÷åñêèå        |    |        |        |        |     |

   |--------------------------+----+--------+--------+--------+-----|

   |     â ò.÷. ô. N 300      |    |        |        |        |     |

   |--------------------------+----+--------+--------+--------+-----|

   |     òåðàïåâòè÷åñêèå      |    |        |        |        |     |

   |--------------------------+----+--------+--------+--------+-----|

   |     èíôåêöèîííûå         |    |        |        |        |     |

   |--------------------------+----+--------+--------+--------+-----|

   |     ãèíåêîëîãè÷åñêèå     |    |        |        |        |     |

   |--------------------------+----+--------+--------+--------+-----|

   |     ïñèõèàòðè÷åñêèå      |    |        |        |        |     |

   |--------------------------+----+--------+--------+--------+-----|

   |     ïðî÷èå               |    |        |        |        |     |

   ------------------------------------------------------------------

 

       --------------------------------

       <*> Ïî  õîäó  äèñëîêàöèè  óêàçàòü  íàñòîÿùåå ìåñòîðàñïîëîæåíèå

   ôîðìèðîâàíèé.

 

               4. Ãîñïèòàëèçàöèÿ âûíóæäåííûõ ïåðåñåëåíöåâ

 

   ------------------------------------------------------------------

   |Íàèìåíîâàíèå|   ×èñëî    |    ×èñëî     |        ×èñëî          |

   | ðàéîíà <*> |ïåðåñåëåíöåâ|ïåðåñåëåíöåâ, |  ãîñïèòàëèçèðîâàííûõ  |

   |            |            | îáðàòèâøèõñÿ |                       |

   |            |            |çà ìåäèöèíñêîé|                       |

   |            |            |   ïîìîùüþ    |                       |

   |            |------------+--------------+-----------------------|

   |            |âñåãî|â ò.÷.|âñåãî| â ò.÷. |âñåãî|   â òîì ÷èñëå   |

   |            |     |äåòåé |     | äåòåé  |-----+-----------------|

   |            |     |      |     |        |     | äåòåé  | ô. 300 |

   |------------+-----+------+-----+--------+-----+--------+--------|

   |     1      |  2  |  3   |  4  |   5    |  6  |   7    |   8    |

   |------------+-----+------+-----+--------+-----+--------+--------|

   |------------+-----+------+-----+--------+-----+--------+--------|

   |------------+-----+------+-----+--------+-----+--------+--------|

   |------------+-----+------+-----+--------+-----+--------+--------|

   |------------+-----+------+-----+--------+-----+--------+--------|

   |ÈÒÎÃΠ      |     |      |     |        |     |        |        |

   ------------------------------------------------------------------

 

       --------------------------------

       <*> Óêàçàòü íàèìåíîâàíèå ðàéîíîâ.

 

       Óìåðëî â ËÏÓ _________, â òîì ÷èñëå äåòåé _________.

 

                5. Ëå÷åáíî - ïðîôèëàêòè÷åñêèå ó÷ðåæäåíèÿ

 

   ------------------------------------------------------------------

   |    Íàèìåíîâàíèå    |N    |×èñëî|×èñëî|×èñëî|Ïîñòóïèëî| Óìåðëî  |

   |     ó÷ðåæäåíèé     |ñòðî-|ó÷-  |ôàê- |ðå-  |---------+---------|

   |                    |êè   |ðåæ- |òè-  |çåðâ-| áîëüíûõ |âñå-|â   |

   |                    |     |äåíèé|÷åñêè|íûõ  |---------|ãî  |ò.÷.|

   |                    |     |     |ðàç- |êîåê |âñå-|â   |    |äå- |

   |                    |     |     |âåð- |     |ãî  |ò.÷.|    |òåé |

   |                    |     |     |íóòûõ|     |    |äå- |    |<*> |

   |                    |     |     |êîåê |     |    |òåé |    |    |

   |                    |     |     |     |     |    |<*> |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |         1          |  2  |  3  |  4  |  5  | 6  | 7  | 8  | 9  |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |I. Ñòàöèîíàðû:      | 01  |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |Ðåñïóáëèêàíñêàÿ     | 02  |     |     |     |    |    |    |    |

   |áîëüíèöà            |     |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |Äåòñêàÿ             | 03  |     |     |     |    |    |    |    |

   |ðåñïóáëèêàíñêàÿ     |     |     |     |     |    |    |    |    |

   |áîëüíèöà            |     |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |Ãîðîäñêèå áîëüíèöû  | 04  |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |Äåòñêèå ãîðîäñêèå   | 05  |     |     |     |    |    |    |    |

   |áîëüíèöû            |     |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |Öåíòðàëüíûå ðàéîííûå| 06  |     |     |     |    |    |    |    |

   |áîëüíèöû            |     |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |Ðàéîííûå áîëüíèöû   | 07  |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |Ó÷àñòêîâûå áîëüíèöû | 08  |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |Ðîäèëüíûå äîìà      | 09  |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |Ðîäèëüíûå îòäåëåíèÿ | 10  |     |     |     |    |    |    |    |

   |(èç ñòðîê 02-08)    |     |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |Ïðî÷èå              | 11  |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |ÂÑÅÃΠ              | 12  |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |II. Äèñïàíñåðû:     | 13  |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |Ïðîòèâîòóáåðêóëåçíûå| 14  |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |Îíêîëîãè÷åñêèå      | 15  |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |Êîæíî -             | 16  |     |     |     |    |    |    |    |

   |âåíåðîëîãè÷åñêèå    |     |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |Ïðî÷èå              | 17  |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |ÂÑÅÃΠ              | 18  |     |     |     |    |    |    |    |

   |--------------------+-----+-----+-----+-----+----+----+----+----|

   |ÈÒÎÃΠ              | 19  |     |     |     |    |    |    |    |

   ------------------------------------------------------------------

 

       --------------------------------

       <*> Äåòè - 0-17 ëåò âêëþ÷èòåëüíî.

 

       ×èñëî ðîäèâøèõñÿ _________, èç íèõ óìåðëî ________.

 

              6. Çàðåãèñòðèðîâàíî èíôåêöèîííûõ çàáîëåâàíèé

 

   ------------------------------------------------------------------

   |           Íàèìåíîâàíèå            |       ×èñëî ñëó÷àåâ        |

   |                                   |----------------------------|

   |                                   |âñåãî|  â òîì ÷èñëå äåòåé   |

   |-----------------------------------+-----+----------------------|

   |                                   |     |âñåãî|èç íèõ äî 1 ãîäà|

   |-----------------------------------+-----+-----+----------------|

   |                                   |     |     |                |

   |               1                   |  2  |  3  |       4        |

   |-----------------------------------+-----+-----+----------------|

   |Âñåãî                              |     |     |                |

   |òîì ÷èñëå:                         |     |     |                |

   |-----------------------------------+-----+-----+----------------|

   |    îñòðûå ðåñïèðàòîðíî - âèðóñíûå |     |     |                |

   |    èíôåêöèè (ÎÐÂÈ)                |     |     |                |

   |-----------------------------------+-----+-----+----------------|

   |    îñòðûå êèøå÷íûå èíôåêöèè (ÎÊÈ) |     |     |                |

   |-----------------------------------+-----+-----+----------------|

   |    àêòèâíûé òóáåðêóëåç (âñå ôîðìû)|     |     |                |

   |-----------------------------------+-----+-----+----------------|

   |    äèôòåðèÿ                       |     |     |                |

   |-----------------------------------+-----+-----+----------------|

   |    ÷åñîòêà                        |     |     |                |

   |-----------------------------------+-----+-----+----------------|

   |    ïåäèêóëåç                      |     |     |                |

   |-----------------------------------+-----+-----+----------------|

   |    êîðü                           |     |     |                |

   |-----------------------------------+-----+-----+----------------|

   |    êîêëþø                         |     |     |                |

   |-----------------------------------+-----+-----+----------------|

   |    âèðóñíûé ãåïàòèò               |     |     |                |

   |-----------------------------------+-----+-----+----------------|

   |    áðþøíîé òèô                    |     |     |                |

   |-----------------------------------+-----+-----+----------------|

   |    ýïèäåìè÷åñêèé ïàðîòèò          |     |     |                |

   |-----------------------------------+-----+-----+----------------|

   |    ïîëèîìèåëèò                    |     |     |                |

   ------------------------------------------------------------------

 

       ×èñëî ïðåäñòàâëåííûõ  ýêñòðåííûõ  èçâåùåíèé  ïî  îñîáî îïàñíûì

   èíôåêöèÿì _____________________,  â ò.÷. ñèáèðñêàÿ ÿçâà _________,

   õîëåðà _______, ÷óìà ______, ïðî÷èå (ïåðå÷èñëèòü) _______________.

 

                             7. Âàêöèíàöèÿ

 

   ------------------------------------------------------------------

   |  Ïðîôèëàêòè÷åñêèå ïðèâèâêè  |   Âñåãî    |â òîì ÷èñëå äåòÿì <*>|

   |-----------------------------+------------+---------------------|

   |            1                |     2      |         3           |

   |-----------------------------+------------+---------------------|

   |Âñåãî                        |            |                     |

   |â òîì ÷èñëå ïðîòèâ:          |            |                     |

   |-----------------------------+------------+---------------------|

   |      òóáåðêóëåçà            |            |                     |

   |-----------------------------+------------+---------------------|

   |      äèôòåðèè               |            |                     |

   |-----------------------------+------------+---------------------|

   |      êîðè                   |            |                     |

   |-----------------------------+------------+---------------------|

   |      ïîëèîìèåëèòà           |            |                     |

   |-----------------------------+------------+---------------------|

   |      êîêëþøà                |            |                     |

   |-----------------------------+------------+---------------------|

   |      ñòîëáíÿêà              |            |                     |

   |-----------------------------+------------+---------------------|

   |      ýïèäåìè÷åñêîãî ïàðîòèòà|            |                     |

   ------------------------------------------------------------------

 

       Êîëè÷åñòâî òóáåðêóëèíîâûõ  ïðîá  ó äåòåé <*> ________,  èç íèõ

   ïîëîæèòåëüíûõ _________.

       Îáñëåäîâàíî ôëþîðîãðàôè÷åñêè ____________.

       --------------------------------

       <*> Äåòè - 0-17 ëåò âêëþ÷èòåëüíî.

 

       Ðóêîâîäèòåëü îðãàíèçàöèè        ______________     ___________

                                          (Ô.È.Î.)         (ïîäïèñü)

 

       Äîëæíîñòíîå ëèöî,   _____________  ____________    ___________

       îòâåòñòâåííîå çà     (äîëæíîñòü)     (Ô.È.Î.)       (ïîäïèñü)

       ñîñòàâëåíèå ôîðìû

 

                          __________________    "__" _______ 200_ ãîä

                          (íîìåð êîíòàêòíîãî      (äàòà ñîñòàâëåíèÿ

                               òåëåôîíà)              äîêóìåíòà)