+------------+
                                                      0003804   
                                                                            No.       +------------
                                                                                         +------------
          _____________________________________________________________________ +------------
                      ( , , /,  )         +------------
                                                                                         +------------
          ____________________________________________________________________ +------------
                            ( , , /,  )   +------------
                                                                                         +------------+
          ___________________________________________       
                       (, -, No., )
   
          No.______________________ ..  No.______  "___"_______ 20__ .

   
    --------------------------------------------------------------------------------------------------
    No. -            -    
       No.   ,  +------------       +------------+-----------
     -  -               (      
                                         )                  
                                                                              
    ----------+------------+------------+----+-------+------+------+---------+-----+------+-----+-----
        1          2           3       4     5     6     7       8      9    10    11   12
    ----------+------------+------------+----+-------+------+------+---------+-----+------+-----+-----
                                                                                      
                                                                                      
                                                                                      
                                                                                      
                                                                                      
    --------------------------------------------------------------------------------------------------
   
         ______________________ ,    No.___________
   
      ____________________________   .
                       ()                                                  +------------------+
      ____________________________    ____________                   
                                 ()                            ()  +------------------+
   
      _______________________     ________________________________________
                        ()                                          ()
   
    : ,   ..________  __ .   _______ ..______.
                                         ()                     ( )  ()
   
       _______________                  ..                 +---------------------+
                                                                                "___"________ 20__ .

                                                                                +---------------------+