هﺪﻨﻨﻛ فﺮﺼﻣ ﺮﻈﻧ
ﺮﻫ ﺎﻤﺷ ﺮﮔا ، ﺪﻳراد ﻪﭽﺑﺎﺘﻛ ﻦﻳا هرﺎﺑ رد يﺮﻈﻧ ﺎﻳ ﺪﻘﻧ
ًﺎﻔﻄﻟ ﺪﻴﻨﻛ ﺖﺴﭘ ﺎﻣ ﻪﺑ و ﺪﻴﺴﻳﻮﻨﺑ ار دﻮﺧ دﺎﻬﻨﺸﻴﭘ نآ ﻦﻴﻳﺎﭘ و ﺪﻴﻨﻛ ﻪﻴﻬﺗ ﻪﺤﻔﺻ ﻦﻳا زا ﻲﭙﻛ ﻚﻳ .
زا ......................................... ﻪﺑ ...........................................
طﻮﺑﺮﻣ پﺎﭼ:............................................................................................................................................................. .......
ﻒﻳدر هرﺎﻤﺷ:...................................................................................................................................................................
ﻪﺤﻔﺻ هرﺎﻤﺷ:........................................................ ..........................................................................................................
دﺎﻬﻨﺸﻴﭘ / ﺖﻠﻋ:................................................................................................................................. ................................
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ﺦﻳرﺎﺗ:...............................................................
مﺎﻧ:...................................................................