Nombre: ______________________________________

Club: _________________________________________
 Tener como mnimo de 14 aos de edad.

____/____/____ _______________ Da Mes Ao

Fecha Firma

Ser miembro activo del Club de Conquistadores.

El nombre de mi club es: _______________

____/____/____ _______________
El nombre de mi Director(a) es: ___________________ Fecha Firma

Significado del nombre de mi Club: ____________________________________________________

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Memorizar y explicar el significado del Objetivo JA.

____/____/____ _______________
Fecha Firma
Leer el libro del Club de Lectura Juvenil del ao en curso y resumirlo en una pgina.
Ttulo del libro: ___________________________________________
Autor(a) del libro: ________________________________________
Nmero de paginas ledas: _____________ ____/____/____ _______________
Fecha Firma

Resumen: _______________________________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
 Memorizar y demostrar su conocimiento en:

a) 12 Apstoles: el nombre de los doce apstoles de Jess.

1. ______________________________
2. ______________________________
3. ______________________________
4. ______________________________
5. ______________________________
6. _____________________________
7. ______________________________
8. ______________________________
9. ______________________________
10. _____________________________
11. _____________________________
12. ____________________________

b) Los frutos del Espritu: la relacin de adjetivos del carcter del cristiano.

1. ______________________________________________________
2. ______________________________________________________
3. ______________________________________________________ ____/____/____ _______________
Fecha Firma
4. ______________________________________________________
5. ______________________________________________________
6. ______________________________________________________
7. ______________________________________________________
8. ______________________________________________________
9. ______________________________________________________
10. _____________________________________________________

Leer y explicar los siguientes versculos:

Romanos 12:12 2 Corintios 20:20

Apocalipsis 21:1-3 Salmos 46
2 Pedro 1:20-21
1 Juan 2:14 ____/____/____ _______________
Fecha Firma
 Estudiar y entender a la persona de Espritu Santo, cmo ella se relaciona, cul es
su papel en el crecimiento espiritual de cada ser humano (presentarlo en una
pgina).

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

____/____/____ _______________
Fecha Firma
 Estudiar con su unidad los eventos finales de la Segunda Venida de Cristo.

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

____/____/____ _______________
Fecha Firma
 A travs del estudio de la Biblia, descubrir el verdadero significado de la
observancia del sbado (presentarlo en una pgina).

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

____/____/____ _______________
Fecha Firma
 Mateo 24
Mateo 25 ____/____/____ _______________ Lectura bblica:
Mateo 26:1-35 Fecha Firma
Mateo 26:36-75
Mateo 27:1-31 Juan 9
Mateo 27:32-56 Lucas 19 Juan 10 Hechos 1
Mateo 27:57-66 Lucas 7:18-28 Lucas 21 Juan 11:1- Hechos 2
Mateo 28 Lucas 8 Lucas 22 46 Hechos 3
Marcos 7 Lucas 10:1-37 Lucas 23 Juan 12 Hechos 4
Marcos 9 Lucas 10:38-42; Lucas 24 Juan 13 Hechos 5
Marcos 10 11:1-13 Juan 1 Juan 14 Hechos 6
Marcos 11 Lucas 12 Juan 2 Juan 15 Hechos 7
Marcos 12 Lucas 13 Juan 3 Juan 16 Hechos 8
Marcos 16 Lucas 14 Juan 4 Juan 17
Lucas 1:14-25 Lucas 15 Juan 5 Juan 18
Lucas 1:26-66 Lucas 16:1-17 Juan 6 Juan 19
Lucas 2:21-38 Lucas 17 Juan 7 Juan 20
Lucas 2:39-52 Lucas 18 Juan 8 Juan 21

Invitar a un amigo para participar de una actividad social de su iglesia o de su

Asociacin/Misin.

Iglesia
Asociacin/Misin

____/____/____ _______________
Fecha Firma

Participar de un proyecto comunitario desde su planificacin hasta su ejecucin.

Proyecto: _____________________________________
Fecha: ________________________________________
Participantes:_________________________________________
_____________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

____/____/____ _______________
Fecha Firma

Debatir: cmo los jvenes adventistas se deben relacionar con las personas en las
diferentes situaciones del diario vivir, tales como:
a) Vecindario
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
b) Colegio
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
 c) Actividades sociales
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

d) Actividades recreativas
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

____/____/____ _______________
Fecha Firma

En una conversacin o evaluacin personal, examinar tus actitudes en dos de los

siguientes temas:
Autoestima Finanzas personales
Relacionamiento familiar Presin del grupo

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________

____/____/____ _______________
Fecha Firma

Preparar una lista que contenga 5 sugerencias de actividades para ayudar a

personas con necesidades especificas y colaborar en la organizacin de una
actividad para esas personas.

1. ______________________________________________________________________
2. ______________________________________________________________________
3. ______________________________________________________________________
4. ______________________________________________________________________
5. ____________________________________________________________________

____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

____/____/____ _______________
Fecha Firma
 Completar la especialidad de TEMPERANCIA.

____/____/____ _______________
Fecha Firma

Preparar un organigrama de la iglesia local y relacionar las funciones de los

departamentos.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
______________________________________________________________________

__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
______________________________________________________

____/____/____ _______________
Fecha Firma

Participar de dos programas involucrando diferentes departamentos de la iglesia

local

Programa 1: _____________________________________
Fecha: ________________________________________
Experiencia:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
___________________________________________________________
 Programa 1: _____________________________________
Fecha: ________________________________________
Experiencia:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
___________________________________________________________

____/____/____ _______________
Fecha Firma

Completar la especialidad de AVENTURERO PARA CRISTO I.

____/____/____ _______________
Fecha Firma

Completar la especialidad de EJERCICIOS DE MARCHAS II.

____/____/____ _______________
Fecha Firma

Recapitular la historia de Nicodemo y relacionarla con el ciclo de la mariposa o

disear el ciclo de la oruga resaltando su significado espiritual (presentar en una
pgina).
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
 _______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

____/____/____ _______________
Fecha Firma

Completar una especialidad en Naturaleza.

Especialidad: ______________________________________________________________
____/____/____ _______________
Fecha Firma

Con un grupo de, mnimo cuatro personas y con la presencia de un consejero

adulto con experiencia, caminar por lo menos 20 kilmetros en un rea rural o
desierta, incluyendo una noche al aire libre o en carpa. Panificar la expedicin y
sus detalles antes de la salida. Durante la caminata efectuar anotaciones sobre el
terreno, flora y fauna observados. Despus usando las anotaciones, participar de
un debate en grupo dirigido por su consejero.
 1. ____________________________________________
2. ____________________________________________
3. ____________________________________________
4. ____________________________________________
5. ____________________________________________
Consejero(a): __________________________________

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

____/____/____ _______________
Fecha Firma
 Completar la especialidad de PIONERISMO.
____/____/____ _______________
Fecha Firma

Completar la siguiente especialidad de VIDA PRIMITIVA..

____/____/____ _______________
Fecha Firma

Completar una especialidad, en una de las siguientes reas:

Especialidad: ______________________________________________________________

____/____/____ _______________
Fecha Firma
 Hacer una presentacin escrita o hablada sobre el respeto que debemos tener para
con la Ley de Dios y las autoridades civiles, enumerando por lo menos 10 principios
de comportamiento moral.

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

1. ______________________________________________________________________
2. ______________________________________________________________________
3. ______________________________________________________________________
4. ______________________________________________________________________
5. ______________________________________________________________________
6. ______________________________________________________________________
7. ______________________________________________________________________
8. ______________________________________________________________________
9. ______________________________________________________________________
10. _____________________________________________________________________
11. ________________________________________________________________

____/____/____ _______________
Fecha Firma
Acompaar a su pastor o anciano de iglesia en una visita misionera o estudio bblico.

Pastor Anciano

Nombre del lder: _____________________________________

Fecha: ________________________________________
Experiencia:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
______________________________________________________________

____/____/____ _______________
Fecha Firma

Completar la especialidad de TESTIFICACION DE MENORES.

____/____/____ _______________
Fecha Firma

Presentar cinco actividades en la naturaleza que pueden ser realizadas los sbados
por la tarde.

____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

____/____/____ _______________
Fecha Firma

Con su unidad, construir cinco muebles de campamento incluyendo el portal del Club.

Nudos usados:__________________________________________
________________________________________________________
Amarras usadas: _______________________________________
________________________________________________________
_______________________________________________________

Nudos usados:_________________________________________
________________________________________________________
Amarras usadas: _______________________________________
________________________________________________________
_______________________________________________________

Nudos usados:__________________________________________
________________________________________________________
Amarras usadas: _______________________________________
________________________________________________________
_______________________________________________________
Nudos usados:__________________________________________
________________________________________________________
Amarras usadas: _______________________________________
________________________________________________________
________________________________________________________

Nudos usados:__________________________________________
_______________________________________________________
Amarras usadas: _______________________________________
________________________________________________________
_______________________________________________________

Nudos usados:__________________________________________
________________________________________________________
Amarras usadas: _______________________________________
________________________________________________________
_______________________________________________________

Nudos usados:_________________________________________
________________________________________________________
________________________________________________________
Amarras usadas: _______________________________________
________________________________________________________
________________________________________________________
________________________________________________________

____/____/____ _______________
Fecha Firma

Con la supervisin de su lder o consejero, conversar con su unidad o Club sobre uno
de los temas:

Modestia cristiana Salud

Recreacin Observancia del sbado
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

____/____/____ _______________
Fecha Firma
 Demostrar conocimiento para encontrar alimentos, a travs de plantas silvestres de
su regin y saber diferenciarlas de plantas toxicas/venenosas.

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

1. ________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
2. ________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
3. ________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_____________________________________________________________________________
4. ________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
5. ________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
6. ________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
7. ________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
8. ________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
9. ________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
10. _______________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________
_________________________________________________________________________
________________________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

____/____/____ _______________
Fecha Firma
 Demostrar conocimiento en cuanto a los procedimientos necesarios en caso de
lesiones o heridas por diferentes animales venenosos y no venenosos.

________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

____/____/____ _______________
Fecha Firma
 Demostrar conocimiento y tcnicas para recorrer senderos en diferentes terrenos,
como: desiertos, bosques, pantanos y ros.

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

____/____/____ _______________
Fecha Firma
Elaboracin original de: GM Erwin Mullisaca Alanoca