┌───────┐

                                                           Êîä 

                                                         ├───────┤

                                           Ôîðìà ïî ÎÊÓÄ │0301005│

                                                         ├───────┤

________________________________________________ ïî ÎÊÏÎ │      

             íàèìåíîâàíèå îðãàíèçàöèè                    └───────┘

 

                                           ┌─────────┬───────────┐

                                             Íîìåð      Äàòà  

                                           │äîêóìåíòà│ñîñòàâëåíèÿ│

                                           ├─────────┼───────────┤

                                    ÏÐÈÊÀÇ └─────────┴───────────┘

                                (ðàñïîðÿæåíèå)

                      î ïðåäîñòàâëåíèè îòïóñêà ðàáîòíèêó

 

                                                 ┌───────────────┐

Ïðåäîñòàâèòü îòïóñê                              │Òàáåëüíûé íîìåð│

                                                 ├───────────────┤

                                                               

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                    ôàìèëèÿ, èìÿ, îò÷åñòâî

 

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                   ñòðóêòóðíîå ïîäðàçäåëåíèå

 

__________________________________________________________________

                äîëæíîñòü (ñïåöèàëüíîñòü, ïðîôåññèÿ)

 

    áåç  ñîõðàíåíèÿ çàðàáîòíîé ïëàòû êàê ðàáîòàþùåìó ïåíñèîíåðó ïî

ñòàðîñòè (ïî âîçðàñòó)

 

íà                    ┌─────────────┐ êàëåíäàðíûõ

                            14     │ äíåé

                      └─────────────┘

 

ñ "___"_________ ____ ã. ïî "___"__________ ____ ã.

 

 

Ðóêîâîäèòåëü îðãàíèçàöèè ___________ _________ ___________________

                          äîëæíîñòü   ëè÷íàÿ       ðàñøèôðîâêà

                                      ïîäïèñü        ïîäïèñè

 

Ñ ïðèêàçîì (ðàñïîðÿæåíèåì)

ðàáîòíèê îçíàêîìëåí _____________________ "__"____________ ____ ã.

                       ëè÷íàÿ ïîäïèñü