АССОЦИАЦИЯ УЧАСТНИКОВ ВЕКСЕЛЬНОГО РЫНКА                  !          Серия          !          Номер           !                          Место для акцепта

                                                                                                                            ----------------------------------------------------

                                                                                                                                !                              !                                !                    _____________________________

                                                                                                                         -----------------------------------------------------!

                                                                                                                                                                                                                     _____________________________

                                                                  В Е К С Е Л Ь   на  __________________

                                                                                                         ^{сумма цифрами}                                                                                             _____________________________

                                                                                                                                                                                                                   Подпись акцептанта

          Дата составления _____________________________                   Место составления ___________________________         _____________________________

          ____________________________________________________________________________________________________      _____________________________

^{полное наименование плательщика, его место нахождения}

         предлагаю уплатить против этого переводного векселя

         ____________________________________________________________________________________________________

 ^{полное наименование векселеприобретателя, его место нахождения}

        __________________________________________________________________________   денежную  сумму в размере

        ____________________________________________________________________________________________________

                                                                            ^{сумма цифрами  и прописью, процентная оговорка}

        ____________________________________________________________________________________________________

       Срок платежа _______________________________________________________________________________________

       Платеж через ________________________________________________________________________________________

                                                                                                                                           ^{наименование домицилиата}

       в ___________________________________________________________________________________________________

                                                                                                                                                     ^{место платежа}

       Наименование векселедателя __________________________________________________________________________

        и его место нахождения_______________________________________________________________________________

                                                                                Подписи векселедателя:

                                              Руководитель                                                                Главный бухгалтер

                                                                                                М.П.