Anexo 3 Formulario Registro Individual

 

 GHPNO  G¶ mn YNJHT]YA

NT]KMA VO^YHGKDHAGKO MN IAOHPHK EHGHT]NYHA MN ]YKIKBA, NEVONA X VYNPHTHÔG TADHKO PHDNEHGHT]NYHA PHDNEHGHT]NYH A MN ]YKIKBA X VYNPHTHÔG VYNPHTHÔG TADHKO MHYNDDHÔG JNGNYKO MN ]YKIKBA, CHJHNGN X TNJ^YHMKM AD^VKDHAGKO

@AOHA

@AYE^OKYHA MN YNJHT]YA HGMHPHM^KO VYA@NTHAGKONT X ]ÈDGHDAT NG CHJHNGN, TNJ^YHMKM AD^VKDHAGKO X ENMHDHGK MNO ]YKIKBA

    o    k    h    d    a    T      g     ô    h    s    h    v    n    r    V

No prnsngtn `areuokrha mnin snr oongkma ng `arek mhjhtko, k eëquhgk a dag ontrk mn heprngtk ng ok `arek eës dokrk y daepontk  pashion. Ok hg`arekdhôg hg`arekdhôg prapar prapardhagkmk dhagkmk mnin snr rnko y mmnihmkengtn nihmkengtn rnspkomkmk dag maduengtkdhôg pkrk pkrk `kdhohtkr oas trëeh trëehtns tns mn hgsdrhpdhôg. Dukoquhnr `kosnmkm hgvkohmkrë no rnjhstra darrnspagmhngtn.

;. MK]A ]AT T JN JNG GNY NYKO KON NT ;.; Kpnoohma pktnrga ]HDAGK ;.9 Oujkr mn gkdhehngta

Kpnoohma ektnrga DAGMAYH

Gaeirns KG]AGHA ;.9.; @ndck mn gkdhehngta

OK VKR VYAPHGDHK E^YHOOA NO KO]A

Måk ;: ;.4.; Nstkma dhvho ;.4.9 D. Hmngthmkm DKTKMA =333:>0 OV

;.4 Gkdhagkohmkm IAOHPHKGA

Ens Kûa NGNYA ;8:3 ;.4.4 Tnxa Caeirn ( S ) Eubnr( )

;.= Mhrnddhôg kdtuko (Dkoon, (Dkoon, Gra., Ragk, Dhumkm, Mnpta.) DKOON 4, G² =60> RAGK PHOOK HGJNGHA NO KO]A, OK VKR

;.0 ]no`.

;.> Mhrnddhôg Vnrekgngtn (Dkoon, Gr Gra., Ragk, Dhumkm, Mnpta.) DKOON 4, G² =60> RAGK PHOOK HGJNGHA NO KO]A, OK VKR k.

Ngthmkm magmn trkikbk

;.: @A]AJYK@ÅK (*)

Dkrja(s) qun mnsnepnûk @HTDKO MN TNJ^YHMKM HGM.

;.3 ]no`.

Mhrnddhôg. NEIAO T.K. NO KO]A KP. B^KG VKIOA HH

]no`. :9=864=6

   r    n    t    s    h    g    h    E

T.G.

NEV. PKODNT@YK

9. EA EA]H ]HPA PA MN OK TAO TAOHD HDH] H]^M ^M 9.; ]hpa mn saohdhtum (daoaqun S magmn darrnspagmk) Ynjhstra Gunva

Yngavkdhôg

9.9 Nspndhkohmkmns (daoaqun S magmn darrnspagmk) Tkoum Adupkdhagko

S

Chjhngn Adupkdhagko

Vr Vrnv nvnngd gdhhôg mn Yh Yhnnsjas sjas Ok Okia iark rkoons

S

Enmh Enmhddhgk mn mnoo ]r ]rkkik ikbba

Nrjagaeåk

S

S

Atras Yn-dktnjarhzkdhôg

Tnjurhmkm Adupkdhagko

S

Nspndh`hqun atras2

Mhrnddhôg2 Dkoon Xkgkdadck nsq. Enrdkma T/G ]noè`aga2 Dngtrko Vhoata Vhoata 9=63060 www.ehgtrkikba.jai.ia

   y      a    n     o    p    e    N  ,    a    b    k     i    k    r    ]      n     m      a    h

S

 

4. NM^ NM^DKD DKDHÔG HÔG I IËTH ËTHDK DK,, HG] HG]NYE NYENMH NMHK K X ENM ENMHK HK  Gaeirn mn ok Hgsthtudhôg Hgsthtudhôg y oujkr magmn dursô nstumhas nstumhas ^GHMKM NM^DK]HPK YNX TKOAEAG

Murkdhôg : KÛAT

]åtuoas aitnghmas IKDCHOONY NG C^EKGHMKMNT

 Gaeirn mn ok Hgsthtudhôg Hgsthtudhôg y oujkr magmn dursô nstumhas nstumhas ^GHPNYTHMKM VÒIOHDK MN NO KO]A

Murkdhôg (ensns ô kkûas) ûas) > KÛAT

^GHPNYTHMKM VÒIOHDK MN NO KO]A

> KÛAT

]åtuoas aitnghmas OHDNGDHKMA NG HGJNGHNYÅK NG JKT X VN]YA[^ÅEHDK HGJNGHNYA NG JKT X VN]YA[^ÅEHDK

=. NM NM^D ^DKD KDHÔ HÔG G T^VN T^VNYH YHAY  AY 

>. NT]^ NT]^MHAT MHAT M MN N VAT] VAT]JYKM JYKMA A (MHV (MHVOAEKM OAEKMA, A, NTV NTVNDHK NDHKOHMKM OHMKMNT, NT, EKN EKNT]YÅK T]YÅK,, MAD]AYKMA, A]YAT)

^GHPNYTHMKM VÒIOHDK MN NO KO]A - NO KO]A

Murkdhôg (snekgks, ensns ô kûas) 4 ENTNT

^GHPNYTHMKM VÒIOHDK MN NO KO]A - NO KO]A

4 ENTNT

DNDKV DAGT^O]HGJ — OK VKR

0 CAYKT

DNDKV DAGT^O]HGJ — OK VKR

0 CAYKT

 Gaeirn mn ok Hgsthtudhôg Hgsthtudhôg y oujkr magmn dursô nstumhas nstumhas

DNDKV DAGT^O]HGJ — OK VKR

0 CAYKT

DNDKV DAGT^O]HGJ — OK VKR

0 CAYKT

DNDKV DAGT^O]HGJ — OK VKR

0 CAYKT

]åtuoas aitnghmas MHVOAEKMA NG NM^DKDHÔG T^VNYHAY X JNT]HÔG MN K^OK MHVOAEKMA NG HGPNT]HJKDHÔG DHNG]Å@HDK DNY]H@HDKMA, JNT]HAG MN OK TNJ^YHMKM HGM^T]YHKO MN KGKOHTHT MN YHNTJA… DNY]H@HDKMA, ACTKT ;366; THT]NEKT MN JNT]HAGXMN OK NG TNJ^YHMKM TKO^M NO ]YKIKBA… DNY]H@HDKMA, VNYEHTAT MN ]YKIKBAT NG DKOHNG]N, KO]^YK, NTVKDHAT DAG@HGKMAT, IOA[^NA X N]H[^N]KMA. DNY]H@HDKMA, EKGHV^OKDHÔG X YNTV^NT]K DAG T^T]KGDHKT VNOHJYATKT, CABKT MN TNJ^YHMKM... DNY]H@HDKMA, HTA ;=66; THT]NEKT MN JNT]HÔG KEIHNG]KO, X HMNG]H@HDKDHÔG

Mhrnddhôg2 Dkoon Xkgkdadck nsq. Enrdkma T/G ]noè`aga2 Dngtrko Vhoata Vhoata 9=63060 www.ehgtrkikba.jai.ia

    o    k    h    d    a    T      g     ô    h    s    h    v    n    r    V    y      a    n     o    p    e    N  ,    a    b    k     i    k    r    ]      n     m      a    h    r    n    t    s    h    g    h    E

 

DNDKV DAGT^O]HGJ — OK VKR

0 CAYKT

DNDKV DAGT^O]HGJ — OK VKR

0 CAYKT

DNDKV DAGT^O]HGJ — OK VKR

0 CAYKT

NPKO^KDHÔG MN KTVND]AT… DNY]H@HDKMA, VYNVKYKDHÔG X YNTV^NT]KT MN NENYJNGDHKT… DNY]H@HDKMA, EN]AMAOAJÅKT X ]ÈDGHDKT MN DAGT^O]AYÅK NG TNJ^YHMKM HGM… DNY]H@HDKMA, VYHENYAT K^SHOHAT IËTHDAT X JNT]HÔG MN TKO^M N CHJHNGN AD^VKDHAGKO.

0. D^Y D^YTAT, TAT, D D^YTH ^YTHOOAT OOAT X A]YAT (NG O OAT AT [^ [^N N TN VKY] VKY]HDHV HDHVÔ) Ô) D^YTAT YNKOHRKMAT

HGT]H]^DHÔG

Murkdhôg (carks, måks ô snekgks)

M^YKDHÔG MNO NPNG]A Ng carks a ensns

:. D^Y D^YTAT, TAT, D^ D^YTHOO YTHOOAT AT X A]Y A]YAT AT MHD MHD]KMA ]KMAT T VAY OK VNY VNYTAGK TAGK G GK]^Y K]^YKO KO NPNG]AT YNKOHRKMAT

HGT]H]^DHÔG

Murkdhôg (Carks, måks ô snekgks)

M^YKDHÔG MNO NPNG]A ng carks a ensns

D^YTAT

DAG@NYNGDHKT X TNEHGKYHAT

A]YAT

3. VYAM VYAM^DD ^DDHÔG HÔG HG HG]NOND] ]NOND]^KO ^KO N HG HGPNT]H PNT]HJKDH JKDHAGNT AGNT YN YNKOHRK KOHRKMKT MKT VAY OK VNYTAGK GK]^YKO HGPNT]HJKDHÔG

HGT]H]^DHÔG

@NDCK

AITNYPKDHAGNT

(OHIYA) CABKT MN TNJ^YHMKM MN OAT MNYHPKMAT MNO VN]YAONA DY^MA, IAOHPHK

YN@HGNYÅK J^KOINY]A PHOOKYYANO

96;4-96;8

OHIYA

8. V^IO V^IOHDKD HDKDHAGNT HAGNT YNKO YNKOHRKM HRKMKT KT V VAY AY O OK KV VNYTAG NYTAGK K GK GK]^YKO ]^YKO HGPNT]HJKDHÔG

HGT]H]^DHÔG

@NDCK

Mhrnddhôg2 Dkoon Xkgkdadck nsq. Enrdkma T/G ]noè`aga2 Dngtrko Vhoata Vhoata 9=63060 www.ehgtrkikba.jai.ia

AITNYPKDHAGN T

    o    k    h    d    a    T      g     ô    h    s    h    v    n    r    V    y      a    n     o    p    e    N  ,    a    b    k     i    k    r    ]      n     m      a    h    r    n    t    s    h    g    h    E

 

;6. NSVN NSVNYHNG YHNGDHK DHK M MN N ]YK ]YKIKBA IKBA Ngthmkm(ns) a Neprnsk(s) magmn prnstô sus snrvhdhas ^GHP ^G HPNY NYTH THMK MKM M V^I V^IOH OHDK DK MN MN NO KO] KO]A A ^GHP ^G HPNY NYTH THMK MKM MV V^I ^IOH OHDK DK MN NO KO]A KO]A ^GHPNYTHMKM V^IOHDK MN NO KO]A

^GHPNYTHMKM V^IOHDK MN NO KO]A

^GHPNYTHMKM V^IOHDK MN NO KO]A

NEVYNTK VYXTNH

NEVYNTK PKODNT@YK HGJNGHNYÅK X TNYPHDHAT HGM^T]YHKONT

Dkrja jass mn mnsnepnûk ûkmmas MADN MADNG] G]N N ([^H ([^HEHD EHDK K JNGNYKO) MADN MADNG] G]N N (HGJ. (HGJ. MN JKT GK]^YKO H) MADNG]N (TNJ^YHMKM HGM. X TKO^M AD^VKDHAGKO) MADNG]N (TNJ^YHMKM HGM. X TKO^M AD^VKDHAGKO) MADNG]N (TNJ^YHMKM HGM. X TKO^M AD^VKDHAGKO) T^VNYPHTAY MN TNJ^YHMKM HGM^T]YHKO X TKO^M AD^VKDHAGKO @HTDKO MN TNJ^YHMKM HGM^T]YHKO X TKO^M AD^VKDHAGKO

Nxpnrhngdhk ]atko

Nxpnrhngdhk Nspndå`hdk

Måk 6;

Ens 68

Kûa 96;:

@ndck mn duoehgkdhôg Måk Ens Kûa 4; ;9 96;:

6;

64

96;3

46

60

96;3

69

63

96;3

4;

;9

96;3

@ndck mn mn hhgghdha

6;

69

96;8

46

60

96;8

6;

63

96;8

4;

;9

96;8

;9

6;

96;3

;>

;6

96;8

93

;6

96;8

98

69

9696

Kûas2

Ensns2

=

9

Kûas2

Ensns2

9

9

;;. MNDOKYKDHAG B^YKMK Xa KG]AGHA ]HDAGK DAGMAYH ekyar mn nmkm, dag D.H. G¶ =333:>0  Nxp. O V, mndokra ikba  burkengta ok vnrkdhmkm mn ehs mktas hgmhdkmas ng no prnsngtn @areuokrha mn Ynjhstra Gkdhagko mn Vra`nshagkons y ]èdghdas ng Chjhngn, Tnjurhmkm Adupkdhagko y Enmhdhgk mno ]rkikba y ksuea pongk rnspagskihohmkm mn ok nxkdthtum mn oas mktas dagshjgkmas, kdajhègmaen ko ekrda onjko vhjngtn y mn  pradnmhehngtas kmehghstrkthvas kmehghstrkthvas ng jng jngnrko< nrko< `hrekgma ng shjga mmnn kdnptkdhôg. Mhrnddhôg2 Dkoon Xkgkdadck nsq. Enrdkma T/G ]noè`aga2 Dngtrko Vhoata Vhoata 9=63060 www.ehgtrkikba.jai.ia

    o    k    h    d    a    T      g     ô    h    s    h    v    n    r    V    y      a    n     o    p    e    N  ,    a    b    k     i    k    r    ]      n     m      a    h    r    n    t    s    h    g    h    E

 

Oujkr y @ndck2 OK VKR 69 MN EKYRA MN 9696  

……………………………… @hrek mno pastuokgtn

* no pugta ;.: snrë oongkma par ok Mhrnddhôg Jngnrko mn ]rkikba, Chjhngn y Tnjurhmkm Adupkdhagko mno Ehghstnrha mn ]rkikba, Nepona y Vrnvhshôg Tadhko.

    o    k    h    d    a    T      g     ô    h    s    h    v    n    r    V    y      a    n     o    p    e    N  ,    a    b    k     i    k    r    ]      n     m      a    h    r    n    t    s    h    g    h    E

Mhrnddhôg2 Dkoon Xkgkdadck nsq. Enrdkma T/G ]noè`aga2 Dngtrko Vhoata Vhoata 9=63060 www.ehgtrkikba.jai.ia