Medical document f 082/u
Approved by the USSR Ministry of Health № 1030   04.10.80 year

R E F E R E N C E   №   ________

Given to     _____________________________________________________________
                    (full name)

_________years old, that he (she) attended a medical examination in the polyclinic __________________________________________________________________
__________________________________________________________________
                                                                 (address)
	Found on the examination _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
	
	For state of health ________________________________________
can be directed to a foreign trip to _______________________
                                                                                                          (country)
for a term of __________________________________________________________________

«____»  _____________________ 200___year.

Stamp         Commission Chairman

                  Commission Members

                             

                                                                 (fill in the name in brackets legibly)