Forduk`r Wnkeporej Hnmel`ej @hutej Wesie @duj`ses` (H@W@) Ynr`us

@s` lnjbej Aekkpo`j (tndaus heraoj) Lete l``s` lnjbej

anjer lej vek`l
FOQD^K Q WNKEWOQEJ HNMEL EJ H^\EJ WEYIE D^J YEY
(H@W@) YNQ@^Y \bk. tnr`de = …./…./17....
lnjt`tes pes`nj \ejbbek kec`r = ...../...../………
Wnjejbbujb mewea (lohtnr Ypns`ek`s, lohtnr,
Jed
Jedee = ......
.........
......
......
......
......
......
......
......
......
......
......
.....
.. W`dp`jej)
Jede Orejb
Jede Orejb \ue
\ue = ......
.........
......
......
......
......
......
......
......
......
......
......
.....
.. Mnj`s Hnked`j .........................................................................
Ekedet Wnkeyejej @duj`ses` (QY, Wushnsdes,
Ek
Eked
edet
et= ....
......
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
.. 5. Keh`
Keh`-k
-keh
eh`8`8 1. Wnrn
Wnrndp
dpue
uejj Hk`j`h)
.......................................................... ...........................................................................
Q\
Q\/Q
/QR
R = ....
......
../.
/...
....
.... Hn
Hnk.k./L
/Lnsnsee ....
......
....
....
....
....
....
....
....
....
....
....
....
.. Ae
Aeb`
b` Re
Rej`
j`te
te ^s
^s`e
`e Yu
Yuau
aurr (R^Y
(R^Y)) Q\
Q\/Q /QRR = .... ......
../.
/...
....
.... Hnk.
Hnk./L
/Lnsnsee ....
......
....
....
....
....
....
....
....
....
....
....
....
..

Hni
Hni.. = ......
.........
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
..... 5. Ced`k 1. \`leh Ced`k Hni. = .........................................................
Hea/Hote = .......................................................... Hea/Hote= ..........................................................
Wr
Wrop
op.. = ....
......
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
.. H^ snan
snanku
kud
d `duj
`duj`s
`ses
es`` = Wrop
Wrop.. = ....
......
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
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..
\n
\nkp
kp.. = ....
......
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
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....
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....
....
.. ..
....
....
....
....
....
....
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....
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.... \nkp
\nkp.. = ....
......
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..
Holn Wos= Holn Wos=

Wndanr` duj`ses` = Lohtnr / A`lej / Wnrewet / ....................

Vehs`j-vehs`j yejb l`anr`hej leked < d`jbbu tnrehc`r
Vehs`j-
Wndanr`ej
Jo. Mnj`s Vehs`j Wear`h vvd Jo. Aetic jtrehutej / Yuahutej / Kohes`
\ejbbek Med Mudkec los`s
jtredushuker pnjyujt`hej
5
1
9
<
\ndpet pndanr`ej `duj`ses` = 5. QY8 1. Wushnsdes8
Wushnsdes8 9. Lohtnr Wrehtnh8 <. Wustu8 >. Hk`j`h @duj`ses` (yejb tnrlefter)

Dej`fnstes` hnmel`ej `hutej (hnkucej, bnmeke hk`j`s)

Rehtu bnmeke t`dauk Kede bnmeke Wnrewetej / t`jlehej
Hnkucej & Bnmeke Hk`j`s
Anjbheh pele kohes` pnjyujt`hej \ejbbek Med Djt Djt Med Cer` \`jlehej
Qewet mekeleruret
j
Wnrlerecej pele kohes` pnjyujt`hej Qewet @jep (tbk....................)
Wnrlerecej ke`j.................................................... L`rumuh hn........................
Hndnrecej kohek (tbk......................... )
Hndnrecej tnrsnaer
Betek Hojl`s` seet `j` (tbk……………….…)
Anjbheh pele a`a`r / hnkopeh dete / hndekuej Yndauc (tbk ……………….)
Anjtok l`snrte` betek Dnj`jbbek (tbk ...................)
Dujtec Leked pnrewetej=
L`ern - L` rudec / dejl`r`
W`jbsej (s`jhop) - Fes`k`tes hnsncetej
Hnmejb
Ynseh jefes
Lnded t`jbb` (:907 I) kna`c ler` setu cer`
Wndanserej hnknjmer ehs`ke
Hnkndecej/hnkudpucej
Hnkndecej/hnkudpucej otot= knjbej/tujbh
knjbej/tujbhe`
e`

X5T
 Hnselerej dnjuruj
Ke`j-ke`j 5. ...........................
.....................................................
..............................
....
1. ...........................
.....................................................
..............................
....
9. .................................................
.........................................................
........
Epehec ele seserej ke`j yejb l``duj`ses` pele seet yejb sede dnjbeked` bnmeke snrupe?
Pe
\`leh

Epehec ele
Peseserej ke`j yejb t`leh l``duj`ses` pele seet yejb sede dnjbeked` bnmeke snrupe?
\`leh
jfordes` hnsncetej ke`jjye (eknrb`, hnke`jej hojbnj`tek
hojbnj`tek,, leked tnrep` oaet-oaetej tnrtnjtu, hodora`l ke`jjye)

Anr`te H W l`pnroknc ler` = (pes`nj, helnr, hnk hnkuerbe,

uerbe, desy
desyerehet,
erehet, .....................)
.....................) ............................................, tejbbek ...../...../........
............................................, ...../...../............
Jede = \ejle tejbej pnkepor \ejle tejbej pndanr` `duj`ses`
Cuaujbej
Cuau jbej ln
lnjbej
jbej pes`n
pes`njj =
\ejbbek = ...../...../..........

(............................)
(........................................)

Forduk`r @jvnst`bes` Hnmel`ej @hutej Wesie @duj`ses` (Otops` Vnraek)

X1T
 FOQD^K Q JVNY\ BEY
HNMEL EJ H^\EJ WEYIE D^J YEY
(Otops` Vnraek)

Rewejiere l`kehuhej oknc =

(jede, `jstejs`, tnknpoj, nde`k)

5. Jede =________________________________________________________

@jstejs` =__________________________________________
=__________________ ______________________________________
______________

\nknpoj/Nde`k =_________________________________________
=__________________ _____________________________
______

1. Jede =________________________________________________________

@jstejs` =__________________________________________
=__________________ ______________________________________
______________

\nknpoj/Nde`k =_________________________________________
=__________________ _____________________________
______

\ejbbek = _____________________ Med = ____________________________

_______________________ _____

Qnspojlnj =

5. Jede = ________
____________
________
________
________
________
______

Cuaujbej lnjbej hesus H@W@ = _________________________________

_______________________ __________

1. Jede = ________
____________
________
________
________
________
______
__

Cuaujbej lnjbej hesus H@W@ = __________________________________

_______________________ ___________

LNJ\ \EY HEY^Y H W

Jede = ____________________________________Knkeh`
_______________________ _____________Knkeh`/Wnrndpuej
/Wnrndpuej

X9T
 \ejbbek kec`r = _____/______/______
_____/______/___ ___
^s`e = _____\ecuj________Aukej______Cer`
_____\ecuj________Auk ej______Cer`
Ekedet = Mekej …………………………
………………………… Jodnr …. Q\/QR ……………….
……………….
Lusuj/Hedpujb……………..
Lusuj/Hedpujb…… ……….. Lnse/Hnkurecej
Lnse/Hnkurece j …………………
Hniedetej ………………….. Heaupetnj …………………………
Wrov`js` ……………………….…
Mudkec seulere hejlujb=

D^J YEY
@duj`ses` tnrlecuku (kna`c ler` 97 cer`, ler` `duj`ses` tnrehc`r)
@duj`ses` \bk Med Jo. Ants NL VVD Iere Wndanr`ej Mudke Kohes` Bnmeke/
(Vehs`j) (@jtre hutej, c los`s pnjyujt`hej Qnehs`
Yua-hutej, @jtre (dk) s`dpejb
dushuker)

* M`he Pe= Qnehs` t`dauk pele tbk ..........................................

..................................... .....
Bnmeke & Rehtu t`daukjye bnmeke ...............................................................
.............................................................................
..............
L`ebjos`s
L`ebjos`s ....................................

@duj`ses` snherejb (leked huruj 97 cer` tnrehc`r) =

@duj`ses` \bk Med Jo. Ants NL VVD Iere Wndanr`ej Mudkec Kohes`
(Vehs`j) (@jtre dushuker) los`s pnjyujt`hej
(dk)

\n
\ndp
dpet
et `d
`duj
uj`s
`ses
es`` = Wu
Wush
shns
nsde
dess Qude
Qudecc Yeh`
Yeh`tt Wr
Wreh
ehtn
tnhh Ywes
Yweste
te

Hk`j`h @duj`ses` Ke`j-ke`j= ______________

______________

X<T
Wndanr`
Wndanr` `duj`ses
`duj`ses`` = Lohtnr
Lohtnr Wnrewet
Wnrewet A`lej
A`lej

HOJL Y QEJ\E L JB J
5. Epehec vehs`j l`s`dpej pele
tndpet yejb snsue`?

1. Epehec vehs`j l`s`dpej pele

sucu yejb snsue`?
(1 ’ 37 I)

9. Epehec l`kehuhej doj`tor`jb

sucu lej pnjietetej sniere anrheke? (sucu l`ietet lue hek`
sncer` lej tnrlepet bref`h pnjietetej sucu)

<. Epehec tnrlepet vehs`j ke`j

snke`j
snke`j Iov`l-50
Iov`l-50 (LW\-CA-C`a
(LW\-CA-C`a,, L\, \l, CA ^j`mnit)
^j`mnit) yejb
yejb
anhuu eteu
anh eteu l`
l`lub
lubee anhu
anhu l` leked
leked tndpet
tndpet pnjy`d
pnjy`dpej
pejej
ej
vehs`j?

>. Epehec tnrlepet aerejb snke`j

vehs`j l` leked tndpet pnjy`dpejej vehs`j?

6. Epehec vehs`j l`s`dpej

an
anrs
rsed
edee lnjnjbe
bejj oa
oaet
et ke`j
ke`j ln
lnjb
jbej
ej pnd`s
nd`sec
ecej
ej le lejj
pnjejl
pnjejleej
eej ye
yejb
jb mnkes
mnkes,, snc`j
snc`jbbe
bbe dnjmed
dnjmed`j
`j t`leh
t`leh tnr
tnrmel
mel``
hojted`jes`/hojted`jes`
hojted`jes`/hojted`jes` s`kejb?
2. Epehec tnrlepet vehs`j yejb
helekuerse eteu dnjbeked` hnrusehej f`s`h l` leked tndpet
pnjy`dpejej vehs`j lej l`p`sechej snrte l`anr` pnjejleej

yejb mnkes?
3. Epehec tnrlepet s`se vehs`j
pnkeyejej snankudjye
snankudjye (kna`c ler` njed med) l` leked tndpet
pnjy`dpejej vehs`j?

0. Epehec tnrlepet vehs`j lnjbej hojl`s` VVD I eteu L

l` leked tndpet pnjy`dpejej vehs`j lej l`p`sechej
snrte l`anr` pnjeleej yejb mnkes?

57. Epehec tndpet pnjy`dpejej vehs`j l`knjbhep` lnjbej

tnrdodntnr yejb anrfujbs` lnjbej ae`h lej tnrhek`ares`?
(Hek`ares` d`j`dek setu hek`/tecuj)

X>T
55. Epehec tnrlepet bnjnretor
yejb anrfujbs
anrfujbs`` lnjbej
lnjbej ae`h ujtuh
ujtuh dnjmed`j
dnjmed`j m`he tnrmel`
tnrmel`
k`str`h peled?

51. Epehec tnrlepet forduk`r

pnjiet
pnjietete
etejj lej pnkepo
pnkeporej
rej tnr
tnrdes
desuh
uh for
fordu
duk`r
k`r H@W@
H@W@ pele
pele
tndpet pnkeyejej `duj`ses`?

59. Epehec tnrsnl`e H`t Ejef`keht`h

pele seet pnkeyejej `duj`ses`?

HNELEEJ WEY NJ YNANK^D D^J YEY

M`he ye,
ye, t`daukjye bnmeke snmeh =
Bnmeke \`leh Pe
\ejbbek Wuhuk
Lnded
Aetuh/p`knh
L`ern
Dujtec
Ynseh Jepes
Hodora`l ke`j=
- L`eantns
- C`pnrtnjs`
- Wnjy
Wnjyeh
eh`t`t he
herl
rl`o
`ove
vesh
shuk
uknr
nr
- Wnjyeh`t b`jmek
- Wnjyeh eh`t`t pe
peru
ru ke`j
e`jjye
(WWOH, \AI, esde, lkk)
- Wnjyeh`t ce cet`
- Hnbejesej
- Bejbbuej ``d dujokob`
- Ced`k
- Ke`j-ke`j=
………………………………………..

Hojl`s` hnsncetej=
- Eknrb` tnrcelep = - tnkur Ele \`leh ele
- oaet Ele \`leh ele
- Eknrb` ke`jjye= Ele, snauthej ______________ \`leh Ele

Wnjboaetej seet `j`=

- Wndehe`ej oaet-oaet stnro`l Ele \`leh ele

X6T
- Wnjboaetej ke`jjye= Ele \`leh ele

Ynauthej ______________________________________________________________________

Q`weyet eknrb` pele hnkuerbe= ____________________________________________________

WNQMEKEJEJ DEJ FNY\EY HK J Y HEY^Y H W WELE WEY NJ

M`he
M`he ye,
ye, tt`d
`dau
aukj
kjye
ye bnme
bnmeke
ke snme
snmehh = Kede
Kede bnme
bnmeke
ke
Bnmeke \`leh Pe
\ejbbek Wuhuk Med / Cer`
Anjbheh l` tndpet sujt`hej
Wnrlerecej l` tndpet sujt`hej
Qued kohek, anjbheh, dnrec & betek
- pele huk`t
- pele a`a`r
- pele dete

Qued- tnrsnaer=
pele duhe
- pele ejtnr`or tuauc
- pele postnr`or tuauc
- pele ejbbote bnreh
- snkuruc tuauc
Lnded t`jbb` : 907
Jynr` hnpeke
Jynr` otot
Knsu
Aetuh/p`knh
L`ern
Dujtec
Ynseh jepes
Huj`jb / `htnr`h
Wnrlerecej
Hnmejb
Hnkndecej/hnkudpucej otot
knjbej / tujbhe`
W`jbsej (s`jhop)
Wnjurujej hnselerej
\ejle-tejle syoh ejef`keht`h
Yeh`t hnpeke
Kndes & hnaes snkuruc tuauc
Wndanjbhehej hnkm.bntec anj`jb
(kncnr/hnt`eh/k`pet pece)
(kncnr/hnt`eh/k`pet
Yeh`t l`snrte` hnkndecej pele knjbej

X2T
yejb l`sujt`h
Ke`j-ke`j= ……………………………….
……………………………….
- …………………………….
- …………………………….
lnjt`tes pnkepor
Bnmeke ewek H@W@ l`hntecu` pnrtede hek` oknc =
Jede = ____________________
Cuaujbej lnjbej pnjlnr`te = __________________________
Wele tejbbek …………………….. med …………

Ekur pnjejbbukejbej hesus H W

Keporej elejye H@W@ l`kehuhej pele tejbbek …………………..… med………
lej l`sedpe`hej hnpele
Jede `jst`tus` = _______________________________

Ekedet = ____________
____________________
________________
___________
___

\`jlehej yejb l`kehuhej oknc pnjnr`de keporej pnrtede =

Dndanr` pnjboaetej
Jede oaet, wehtu, los`s lej iere pndanr`ej oaet=
Jede oaet (usecehej Rehtu pndanr`ej los`s Iere pndanr`ej
tejbbek Med
jede bnjnr`h)

Ces`k pnjboaetej=
dndae`h
t`leh ele hndemuej
dndauruh
sndauc pele tejbbek ………./…………../…………
………./…………../…………
Dnrumuh
Rehtu dnrumuh
dnrumuh = tejbbek…………….…
tejbbek…………….… med………….
Qumuhej hnpele =
Jede `jst`tus` = _________________________

X3T
Ekedet = _______________
_______________________
__________
__

Qumuhej pnrtede H@W@ t`ae tejbbek …………… med ………… pele

Jede =_____________________________
Meaetej =____________________________
Jede `jst`tus` lej ekedet = _____________________________

Bnmeke hk`j`s/hneleej seet l` tndpet rumuhej =

Wndnr`hseejj f`s`h=
Wndnr`hsee

Wndnr`hseej pnjujmejb=

E. Keaoretor`ud=

X0T
 A. Qojtbnj

I. I\-Y
I\-Yie
iej/
j/DQ
DQ@@

L. Yn
Ynro
roko
kob`
b`/Y
/Ywe
weaa WIQ
WIQ

L`ebjos`s = _______________________
\`jlehej =
Qewet @jep Qewet Mekej Dndanr` pnjboaetej

Jede oaet, wehtu, los`s lej iere pndanr`ej oaet=

X57T
 Jede oaet (usecehej Rehtu pndanr`ej Los`s Iere pndanr`ej
tejbbek med
jede bnjnr`h)

\`jlehej ke`j = _________________________________

______________________ ___________

Ces`k pnjboaetej=
dndae`h
t`leh ele hndemuej
dndauruh
sndauc pele tejbbek ………./…………../………
………./…………../…………
…
Qumuhej hnlue H W
Rehtu dnrumuh = tejbbek………………………………
tejbbek……………………………… med…………. Oknc=
Jede =__________________________________
Meaetej = __________________________________
_____________________ _____________
Qumuhej t`ae tejbbek …………… med ………… pele
Jede `jst`tus` = ________________________________
Ekedet = _________________
_________________________
_______________
_______

Bnmeke hk`j`s/hneleej seet l` tndpet rumuhej =

Wndnr`hseejj f`s`h=
Wndnr`hsee

X55T
Wndnr`hseej pnjujmejb=
E. Keaoretor`ud=
Keaoretor`ud=

A. Qojtbnj

I. I\-Y
I\-Yiiej
ej/D
/DQ@
Q@

X51T
 L. Yn
Ynro
roko
kob`
b`/Y
/Ywe
weaa WIQ
WIQ

L`ebjos`s = _______________________
\`jlehej =
Qewet @jep Qewet Mekej Dndanr` pnjboaetej

Jede oaet, wehtu, los`s lej iere pndanr`ej oaet=

Jede oaet (usecehej Rehtu pndanr`ej Los`s Iere pndanr`ej
tejbbek med
jede bnjnr`h)

\`jlehej ke`j = _________________________________

______________________ ___________

Ces`k pnjboaetej=
dndae`h
t`leh ele hndemuej

X59T
 dndauruh
sndauc pele tejbbek ………./…………../………
………./…………../…………
…
Qumuhej hnt`be H W
Rehtu dnrumuh = tejbbek………………………………
tejbbek……………………………… med…………. Oknc=
Jede = ___________________________________
Meaetej = ___________________________________
______________________ _____________
Qumuhej t`ae tejbbek …………… med ………… pele
Jede =_____________________________
Meaetej =_____________________________
Jede `jst`tus` lej ekedet = _____________________________

Bnmeke hk`j`s/hneleej seet l` tndpet rumuhej =

Wndnr`hseejj f`s`h=
Wndnr`hsee

Wndnr`hseej pnjujmejb=

X5<T
E. Keaoretor`ud=

A. Qojtbnj

I. I\-Y
I\-Yie
iej/
j/DQ
DQ@@

L. Yn
Ynro
roko
kob`
b`/Y
/Ywe
weaa WIQ
WIQ

X5>T
L`ebjos`s = _______________________
\`jlehej =
Qewet @jep Qewet Mekej Dndanr` pnjboaetej

Jede oaet, wehtu, los`s lej iere pndanr`ej oaet=

Jede oaet (usecehej Rehtu pndanr`ej Los`s Iere pndanr`ej

tejbbek med
jede bnjnr`h)

\`jlehej ke`j = _________________________________

______________________ ___________

Ces`k pnjboaetej=
dndae`h

t`leh ele hndemuej

dndauruh
sndauc pele tejbbek ………./…………../………
………./…………../…………
…
CEY K WNDNQ HYEEJ KEAOQE\OQ ^D
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
………………………………………………………………………...

X56T
CEY K WNDNQ HYEEJ WNJ^JMEJB KE J
E. Qojtbnj

A. I\-Y
\-Yiej
ej/D
/DQ
Q@

I. Yn
Ynro
roko
kob`
b`/Y
/Ywe
weaa WIQ
WIQ

CEY K EHC Q
YNDA^C YNDW^QJE
YNDA^C LNJBEJ BNMEKE Y@YE ANQ^WE =

X52T
 DNJ@JBBEK, tejbbek
tejbbek …………….…………… med ………………….

HNY DW^KEJ LOH\NQ PEJB DNQERE\ WEK JB EHC Q

L@EBJOY@Y =
5.
1.
9.
YNAEA HNDE\@EJ = _________________________

CEY K WNDNQ HYEEJ ^M VEHY J (epea`ke vehs`j l`h`r`d ujtuh l`pnr`hse hn WWODJ-AWOD)
Wntubes AWOD-Aeke` Anser WOD Wrov`js`
- Jede= ……………………..
- @jst`tus`= ………………….

Rehtu pnjbeda`kej sedpnk

- \ejbbek= ……/……./……
- Rehtu= ………………..
Mudkec sedpnk*= …………………..
Jo Aetic. = …………………………
Ces`k= \ns \ohs`s`tes=
\ohs`s`tes= ………………….. ……….. \ns Ytnr`k`tes= ……………. ……………………..
……………………..

*Mudkec Yedpnk=
Yedpnk=

Jo. Ejt`bnj Vokudn sedpnk \otek sedpkn

(dk eteu los`s)

X53T
 5 Iov`l-50 > dk, 57 los`s 10 v`ek

\EJLE \EJBEJ WNJB Y FOQD^K Q JVNY\ BEY

( ___________________ ) ( __________________ )
Meaetej= Meaetej =

Q JI EJ HQOJOKOB Y H W

X50T