ILOVA
1-ILOVA
| ____________________ “____” -son ___________________________________ TMEK | ||||
| ( Respublika, viloyat, shahar) |
(shahar, tuman, tumanlararo, ixtisoslashtirilgan) | |||
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| 1. Koʻrik boshlangan sana ______________ Oʻtkazilgan sana _____________________ Tugatilgan sana _____________________ Koʻrik oʻtkazilgan joy______________________________________________________ | ||||
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(aniq koʻrsatilsin) | |||
| 2. F.I.O._________________________________________________________________ ________________________________________________________________________ | ||||
| 3. Tugʻilgan kuni, oyi, yili __________________________________________________ 4. Pasport seriyasi va raqami ________________________________________________ kim tomonidan berilgan____________________________________________________ 5. Manzili_______________________________________________________________ ________________________________________________________________________ ______________________________________ tel._______________________________ 6. TMEKga murojaat etish sababi ____________________________________________ 7. TMEKga murojaat etish __________________________________________________ | ||||
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(birlamchi, qayta) | |||
| 8. TMEK I shakl boʻyicha shifr ___________________MKB 10 boʻyicha ________________ 9. Maʼlumoti: yoʻq, umumiy oʻrta taʼlim, oʻrta maxsus, kasb-hunar, oliy (tagiga chizilsin) | ||||
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10. Ish joyi _____________________________________________________________ | ||||
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(tagiga chizilsin) | ||
| 15. Bajarayotgan ishni turi va sharoiti ________________________________________ _______________________________________________________________________ 16. Ishni qanday bajaradi __________________________________________________ ________________________________________________________________________ 17. Ishlamaydi ___________________________________________________________ | ||||
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(qachondan, sababi) | |||
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18. Kasbiy malaka: yetarli, yetarli emas, past, yoʻq (tagiga chizilsin) | ||||
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| 23. Shikoyatlari___________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ | ||||
| 24. Klinik-mehnat anamnezi _________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ | ||||
| 25. Alohida obyektiv maʼlumotlar: boʻyi __________sm., vazni ___________ kg. | ||||
| 26. Vaqtincha mehnatga layoqatsizlik dinamikasi (oxirgi 12 oyda)____________________ ________________________________________________________________________________________________________________________________________________ | ||||
| 27. Vrach ekspertlarning koʻrik natijalari: 27a. Ekspert — terapevt koʻrigi ______________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ | ||||
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_________ (________________) | ||
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imzo |
F.I.O. |
| 27b. Ekspert — jarroh koʻrigi ______________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ | ||||
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| | | | ___________ (_______________) | |
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imzo |
F.I.O. |
| 27v. Ekspert-nevrolog koʻrigi _______________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ | ||||
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| | | | ___________ (_______________) | |
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imzo |
F.I.O. |
| 27g. Boshqa ekspert mutaxassislar koʻrigi _____________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ | ||||
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| | | | ___________ (_______________) | |
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imzo |
F.I.O. |
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28. Tibbiy tekshirish natijalari (funksional, laborator, rentgenologik va b.) ______ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ | ||||
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29. Klinik — ekspert tashxis: | ||||
| 29b. Yoʻldosh _____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 29v. Asoratlari __________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ | ||||
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TMEK XULOSASI | ||||
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30. Organizm funksiyasini buzilish turi: | ||||
| 33. Nogironlik guruhi _____________________________________________________ 34. Kasbiy mehnat layoqati yoʻqotilganlik darajasi ____________________ (______%) | ||||
| | | | (soʻz bilan yoziladi) | |
| 35. Nogironlik sababi _____________________________________________________ | ||||
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(amaldagi qonunchilik asosida) | |||
| 36. Nogironlik muddati ____________________________________________________ | ||||
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(amaldagi qonunchilik asosida) | |||
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37. Nogironlikning davriy muddati: 20_____ yil “1” ________________________ gacha | ||||
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(zarurat tugʻilganda) | ||
| 40. TMEK xulosasini chiqarish uchun asos boʻlgan hujjatlar: _______________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ | ||||
| 41. TMEK xulosasini qisqacha asoslash: _______________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ | ||||
| 42. Qayta TMEK koʻrigidan oʻtayotganlar uchun: 42a. DPMda dispanser koʻrik oʻtkazilishi darajasi ______________________________ | ||||
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(sitematik, epizodik, oʻtkazilmagan) | ||
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42b. TMEKka asosli yoki asossiz yuborilgan (tagiga chizilsin) | ||||
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| 45. TMEK raisi: |
________________ |
(___________________) | ||
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Aʼzolari: |
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(F.I.O.) | ||
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(___________________) | ||
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(F.I.O.) | ||
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(___________________) | ||
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(F.I.O.) | ||
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(___________________) | ||
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(F.I.O.) | ||
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(___________________) | ||
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(F.I.O.) | ||
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| | M.Oʻ. | | | |
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Koʻrik dalolatnomasi sifati va nazorat koʻrik natijalari boʻyicha Bosh TMEKning | ||||
| ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ | ||||
| Xulosa: _________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ | ||||
| Koʻrsatma va eʼtirozlar:___________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ | ||||
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| Bosh TMEK raisi |
_____________ |
(___________________) | ||
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(F.I.O.) | ||
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Aʼzolari: |
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___________ |
(___________________) | |
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(F.I.O.) | |
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_____________ |
(___________________) | |
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(F.I.O.) | |
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_____________ |
(___________________) | |
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M.Oʻ. |
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(F.I.O.) | |
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_____________ |
(___________________) | |
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(F.I.O.) | |
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REABILITATSIYA BOʻYICHA TAVSIYALAR | ||||
| I. Tibbiy reabilitatsiya: | ||||
| Qayta tiklash uchun davolash usuli ____________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ | ||||
| Rekonstruktiv operatsiyaga tavsiya ____________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________ | ||||
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(operatsiya turi koʻrsatilsin) | ||||
| Yordamchi texnik vositalariga tavsiya __________________________________________ | ||||
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(turi koʻrsatilsin) | ||
| Protez mahsulotiga tavsiya __________________________________________________ | ||||
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(turi koʻrsatilsin) | ||
| Ortopedik mahsulotga tavsiya _______________________________________________ ________________________________________________________________________ | ||||
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(turi koʻrsatilsin) | ||
| Eshitish apparatiga tavsiya _________________________________________________ Nogironlik aravachasiga tavsiya ______________________________________________ | ||||
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(turi koʻrsatilsin) | ||
| II. Ijtimoiy reabilitatsiya: | | | | |
| Kasbiy-ergonomik moslamaga tavsiya _________________________________________ ________________________________________________________________________ Reabilitatsiya markaziga tavsiya ______________________________________________ ________________________________________________________________________ Infrastrukturani moslashtirilishiga tavsiya _________________________________ ________________________________________________________________________ ________________________________________________________________________ | ||||
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Maxsus oʻquv muassasalarida oʻqish va tarbiya olishga tavsiya _______________________ | ||||
| III. Kasbiy reabilitatsiya: | ||||
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Kasb-hunarga oʻqitilishga tavsiya, ish joyida, oʻrta-maxsus, oliy oʻquv yurtlarida va maxsus bilim maskanida ___________________________________________________ | ||||
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Mehnat joyi uchun maxsus-texnik vositalarni, moslamalarni yaratib berishga tavsiya ________________________________________________________________________________________________________________________________________________Tavsiya etilgan mehnat turlari ______________________________________________ ________________________________________________________________________________________________________________________________________________ | ||||
2-ILOVA
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______________ viloyat (Respublika) | ||
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| Sizdan____________________________________________________manzilda yashovchi _____________________________________________________________________ni | ||||
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(F.I.O.) | ||||
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(soʻz bilan yoziladi) |
(sana) |
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| oʻtgan. Nogironlik toʻgʻrisidagi maʼlumotnoma seriyasi _________№_________________ Koʻrik dalolatnomasidan koʻchirma seriyasi_______________№________________ | ||||
| TMEK bayonnomasi №_______ |
_____________________ |
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(sana) |
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| №______- sonli TMEK raisi: |
___________ |
_______________________ | ||
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(imzo) |
(F.I.O.) | |
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M.Oʻ. |
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3-ILOVA
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QABUL QILISH-TOPSHIRISH DALOLATNOMASI | ||||
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| “_____”_______________20___yil. | | | ||
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| Biz quyidagi imzo chekuvchilar ______-sonli TMEK raisi________________________ | ||||
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(F.I.O) | |
| hujjatni topshiruvchi va fuqaro_____________________________________________ | ||||
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(nogiron, toʻlov puli oluvchi yoki ularning qonuniy vakili) | |||
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hujjatni qabul qilib oluvchi, quyidagi hujjatlarni qabul qilish-topshirish toʻgʻrisida ushbu dalolatnomani tuzdik. | ||||
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1. Koʻrik ishi (koʻrik dalolatnomalari va mavjud hujjatlar)________varaqdan iborat. | ||||
| | 1. ____________________________________________________ 2. ____________________________________________________ 3. ____________________________________________________ 4. ____________________________________________________ 5. ____________________________________________________ 6. ____________________________________________________ 7. ____________________________________________________ | |||
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| Topshirdim ______-sonli TMEK raisi __________ |
______________________ | |||
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(imzo) |
(F.I.O) | |
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Qabul qildim |
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__________ |
______________________ | |
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(imzo) |
(F.I.O) | |
4-ILOVA
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Budjetdan tashqari Pensiya jamgʻarmasi ________________tuman (shahar) boʻlimiga | ||
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| __________________________________________________ |
___________ | |||
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(F.I.O.) |
(tugʻilgan sanasi) | ||
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__________________________________________________________manzilda yashovchi | ||||
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(soʻz bilan yoziladi) |
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“_____”______________ 20____yildan nogiron (toʻlov puli oluvchi) sifatida _____________________________________________-sonli TMEK roʻyxatiga olindi. | ||||
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| _______sonli TMEK raisi ___________ |
______________________ | |||
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(imzo) |
(F.I.O.) | ||
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M.Oʻ. |
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| Topshirilgan sana “___” ________20___y ________ |
________________________ | |||
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(imzo) |
(TMEK xodimining F.I.O.) | |
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Qabul qilingan sana “___”______20___y ________ |
________________________ | |||
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(imzo) |
(BTPJ xodimining F.I.O.) | |
5-ILOVA
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Budjetdan tashqari Pensiya jamgʻarmasi _________________tuman (shahar) boʻlimiga | ||
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| Asosiy individual parametrlar _____________________________________________ | ||||
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(F.I.O.) | ||
| ______________________________ Pasport seriyasi ______№___________________ | ||||
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Yashash manzili___________________________________________________________ nogironlik guruhi _______________sababi___________________________________ muddati ___________________________________yilgacha, kasbiy mehnat layoqatini yoʻqotilish darajasi_______________(%) muddati _____________yilgacha | ||||
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(soʻz bilan yoziladi) |
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| Nogironlik toʻgʻrisida maʼlumotnoma seriyasi _______№________________ | ||||
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| Koʻrik dalolatnomasidan koʻchirma seriya ____________№_________________ | ||||
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| Bayonnoma №_____ “____”_________________ | ||||
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(sana) |
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| ______sonli TMEK raisi ______________ |
______________________ | |||
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(imzo) |
(F.I.O.). | ||
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M.Oʻ. |
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| Topshirilgan sana “__” _______20___y _________ | ________________________ | |||
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(imzo) |
(TMEK xodimining F.I.O.) | |
| Qabul qilingan sana “__”_______20__y _________ |
________________________ | |||
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(imzo) |
(BTPJ xodimining F.I.O.) | |
6-ILOVA
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______________ viloyat (Respublika) | |||||
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Budjetdan tashqari Pensiya jamgʻarmasi _________________tuman (shahar) boʻlimi 20_____yilning ______________ oyida vafot etgan nogironlar (toʻlov puli oluvchilar) roʻyxatini yubormoqda. | |||||||||
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T/r |
F.I.O. |
Tugʻilgan sanasi |
Pasport seriyasi, raqami |
Vafot etgan sanasi | |||||
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| BTPJ boʻlim boshligʻi ________________ |
___________________ | ||||||||
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(imzo) |
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(F.I.O.) | |||
| | M.Oʻ. | | | | | | | | |