1g Kwc

G‡óU kvLv KZ©„K c~iYxq ivRavbx Dbœqb KZ…©cÿ wnmve kvLvi Rb¨
Av‡e`bcÎ cÖvwß bs
MÖn‡bi ZvwiLt
ivRDK feb, XvKv|
mswkøó †`‡ki †bvUvix cvewjK
WªvdU cÖ`v‡bi m¤¢ve¨ ZvwiLt /evsjv‡`k `~Zvev‡mi mswkøó
Av‡e`b MÖnYKvixi ¯^vÿit Rvgvb‡Zi Wjvi D‡Ëvj‡bi Av‡e`bcÎ Kg©KZ©vi ¯^v¶i I mxj‡gvniK…Z
1(GK) Kwc Qwe|

c~e©vPj : 3 / 5 / 7.5 / 10 KvVv (†hŠ_ Av‡e`bKvixi †¶‡Î

Df‡qi mZ¨vwqZ Qwe mshy³
K| Rvgvb‡Zi Wjvi †di‡Zi Rb¨ Av‡e`bKvixi Z_¨ t (Av‡e`bKvix KZ©„K c~iYxq) Ki‡Z n‡e)|

(1) bvg t (K)................................................................................(L)..........................................................................................

(2) wcZv/¯^vgxi/ bvg t ...................................................................(L)gvZvi bvg..............................................................................
(3) Rvgvb‡Zi e¨vsK iwk`/GdwWwW bs/wUwU bs t.................................................ZvwiLt.............................................Bmy¨K…Z e¨vs‡Ki bvg
.................................................................†`k.........................................................(†iwgU¨vÝ msµvšÍ g~j iwk` mshy³ Ki‡Z n‡e)|
(4) Wjv‡ii cwigvb t (As‡K) ................................................(K_vq) ..............................................................................................
(5) Av‡e`bKvixi e¨vs‡Ki kvLvmn wnmve b¤^i t (†`kx/we‡`kx) ..............................................................................................................
(6) †hŠ_ Av‡e`bKvixMY GKK bv‡g †PK cÖvwßi †ÿ‡Î t mv`v KvM‡R ÿgZv Ac©Y cÎ Rgv w`‡Z n‡e|
(7) Av‡e`bKvixi WvK †hv‡M WªvdU †c‡Z B”QzK n‡j t c~Y© wVKvbv:............................................................................................................
(G †ÿ‡Î WvK PvR© KZ©b Kiv n‡e)
(8) †`kxq gy`ªvq WªvdU †c‡Z B”QzK n‡j t wnmve bs...................................e¨vsK...........................................kvLv.....................................
(9) ¯^vÿit (Av‡e`bc‡Îi Abyi~c 3wU) 1|..................................2|...................................3|................................Zvs .........................
L| G‡óU kvLv KZ©„K c~iYxq t (mwVK n‡j wUK √ w`b, mwVK bv n‡j X w`b)
(1) Av‡e`bKvixi mwVK mwVK wcZv/¯^vgx/gvZvi mwVK mwVK †iwgU¨Ý mwVK mwVK ¯^vÿi mwVK mwVK Qwe mwVK mwVK
bvg bq bvg bq msµvšÍ bq bq bq
iwk`
(2) †KvW bs...................................................
(3) Wjv‡ii cwigvb t (As‡K)...........................................(K_vq)......................................................................................................
(4) kvLvi gZvgZ t Rbve/ †eMg...................................................................................................................................................†K
......................................................................................................Wjvi/UvKv cÖ`v‡bi e¨e¯’v †bqv hvq|

........................................ .................................. ................................

wnmve mnKvix /wnmve iÿK mn-cwiPvjK (&G‡óU) Dc-cwiPvjK (G‡óU)
M| wnmve kvLvi KiYxq t
(1) wnmve kvLvi †iwRóªv‡i AšÍf~³ © c„ôv bs.......................... UvKvi cwigvY..............................................ZvwiLt.......................................
(2) Av‡e`bcÎ †cÖwiZe¨ e¨vs‡Ki bvg......................................................................kvLvi bvg..............................................................
(3) gZvgZ t Av‡e`bKvix Rvgvb‡Zi Wjvi Rgv nIqv wbwðZ mv‡c‡ÿ mswkøó e¨w³‡K wewa †gvZv‡eK PvR© KZ©b K‡i ivRD‡Ki wnmve
bs..................................................................................n‡Z Aewkó Wjv‡ii GKwU WªvdU †`qv hvq|

................................................... ............................... ..................................

wnmve mnKvix / wnmve iÿK (g~jab) mn.cwiPvjK (g~jab) Dc-cwiPvjK (wnmve)

N| e¨vsK KZ…©K c~iYxq t

(1) e¨vsK weeiYx‡Z Av‡e`b d‡g©i Wjvi AšÍf~©³ wK-bv nu¨v bv e¨vsK weeiYx‡Z Rvgvb‡Zi Wjvi AšÍf~³ wK-bv nu¨v bv
(2) Rbve/†eMg...................................................................wnmve bs-.............................................. e¨vsK........................................
..............................kvLv ............ ........................................ eive‡i ...................................... Wjvi n‡Z PvR© KZ©b K‡i ivRD‡Ki wnmve
bs....................................n‡Z Aewkó Wjvi Wªvd&U . bs ....................................... ZvwiL....................................†gvZv‡eK Bmy¨ Kiv n‡jv|

WªvdU MÖnYKvixi ¯^vÿi e¨vsK Kg©KZ©vi ¯^vÿi I mxj

(†PK MÖnYKvix Av‡e`bKvix bv n‡j †PK MÖn‡Yi ÿgZv AcY© cÎ mn Df‡qi Qwe mswkøó e¨vs‡K `vwLj Ki‡Z n‡e)

...................................................................................................................................................................................................
Av‡e`bcÎ cÖvwß bs ivRavbx Dbœqb KZ…©cÿ
ZvwiL Av‡e`bKvixi Ask
ivRDK feb, XvKv|
bvg t .....................................................................................................................................
WªvdU cÖ`v‡bi m¤¢ve¨ ZvwiL t ...............................................

mxj I ¯^vÿi
 2q Kwc
G‡óU kvLv KZ©„K c~iYxq ivRavbx Dbœqb KZ…©cÿ e¨vs‡Ki Rb¨
Av‡e`bcÎ cÖvwß bs
MÖn‡bi ZvwiLt
ivRDK feb, XvKv|
WªvdU cÖ`v‡bi m¤¢ve¨ ZvwiLt
Av‡e`b MÖnYKvixi ¯^vÿit Rvgvb‡Zi Wjvi D‡Ëvj‡bi Av‡e`bcÎ

c~e©vPj : 3 / 5 / 7.5 / 10 KvVv

K| Rvgvb‡Zi Wjvi †di‡Zi Rb¨ Av‡e`bKvixi Z_¨ t (Av‡e`bKvix KZ©„K c~iYxq)

(1) bvg t (K)................................................................................(L)..........................................................................................

(2) wcZv/¯^vgxi/ bvg t ...................................................................(L)gvZvi bvg..............................................................................
(3) Rvgvb‡Zi e¨vsK iwk`/GdwWwW bs/wUwU bs t.................................................ZvwiLt.............................................Bmy¨K…Z e¨vs‡Ki bvg
.................................................................†`k.........................................................(†iwgU¨vÝ msµvšÍ g~j iwk` mshy³ Ki‡Z n‡e)|
(4) Wjv‡ii cwigvb t (As‡K) ................................................(K_vq) ..............................................................................................
(5) Av‡e`bKvixi e¨vs‡Ki kvLvmn wnmve b¤^i t (†`kx/we‡`kx) ..............................................................................................................
(6) †hŠ_ Av‡e`bKvixMY GKK bv‡g †PK cÖvwßi †ÿ‡Î t mv`v KvM‡R ÿgZv Ac©Y cÎ Rgv w`‡Z n‡e|
(7) Av‡e`bKvixi WvK †hv‡M WªvdU †c‡Z B”QzK n‡j t c~Y© wVKvbv:............................................................................................................
(G †ÿ‡Î WvK PvR© KZ©b Kiv n‡e)
(8) †`kxq gy`ªvq WªvdU †c‡Z B”QzK n‡j t wnmve bs...................................e¨vsK...........................................kvLv.....................................
(9) ¯^vÿit (Av‡e`bc‡Îi Abyi~c 3wU) 1|..................................2|...................................3|................................Zvs .........................
L| G‡óU kvLv KZ©„K c~iYxq t (mwVK n‡j wUK √ w`b, mwVK bv n‡j X w`b)
(1) Av‡e`bKvixi mwVK mwVK wcZv/¯^vgx/gvZvi mwVK mwVK †iwgU¨Ý mwVK mwVK ¯^vÿi mwVK mwVK Qwe mwVK mwVK
bvg bq bvg bq msµvšÍ bq bq bq
iwk`
(2) †KvW bs...................................................
(3) Wjv‡ii cwigvb t (As‡K)...........................................(K_vq)......................................................................................................
(4) kvLvi gZvgZ t Rbve/ †eMg...................................................................................................................................................†K
......................................................................................................Wjvi/UvKv cÖ`v‡bi e¨e¯’v †bqv hvq|

........................................ .................................. ................................

wnmve mnKvix /wnmve iÿK mn-cwiPvjK (&G‡óU) Dc-cwiPvjK (G‡óU)
M| wnmve kvLvi KiYxq t
(1) wnmve kvLvi †iwRóªv‡i AšÍf~³ © c„ôv bs.......................... UvKvi cwigvY..............................................ZvwiLt.......................................
(2) Av‡e`bcÎ †cÖwiZe¨ e¨vs‡Ki bvg......................................................................kvLvi bvg..............................................................
(3) gZvgZ t Av‡e`bKvix Rvgvb‡Zi Wjvi Rgv nIqv wbwðZ mv‡c‡ÿ mswkøó e¨w³‡K wewa †gvZv‡eK PvR© KZ©b K‡i ivRD‡Ki wnmve
bs..................................................................................n‡Z Aewkó Wjv‡ii GKwU WªvdU †`qv hvq|

................................................... ............................... ..................................

wnmve mnKvix / wnmve iÿK (g~jab) mn.cwiPvjK (g~jab) Dc-cwiPvjK (wnmve)

N| e¨vsK KZ…©K c~iYxq t

(1) e¨vsK weeiYx‡Z Av‡e`b d‡g©i Wjvi AšÍf~©³ wK-bv nu¨v bv e¨vsK weeiYx‡Z Rvgvb‡Zi Wjvi AšÍf~³ wK-bv nu¨v bv
(2) Rbve/†eMg...................................................................wnmve bs-.............................................. e¨vsK........................................
..............................kvLv ............ ........................................ eive‡i ...................................... Wjvi n‡Z PvR© KZ©b K‡i ivRD‡Ki wnmve
bs....................................n‡Z Aewkó Wjvi Wªvd&U . bs ....................................... ZvwiL....................................†gvZv‡eK Bmy¨ Kiv n‡jv|

WªvdU MÖnYKvixi ¯^vÿi e¨vsK Kg©KZ©vi ¯^vÿi I mxj

(†PK MÖnYKvix Av‡e`bKvix bv n‡j †PK MÖn‡Yi ÿgZv AcY© cÎ mn Df‡qi Qwe mswkøó e¨vs‡K `vwLj Ki‡Z n‡e)
 3q Kwc
G‡óU kvLv KZ©„K c~iYxq ivRavbx Dbœqb KZ…©cÿ G‡óU kvLvi Rb¨
Av‡e`bcÎ cÖvwß bs
MÖn‡bi ZvwiLt
ivRDK feb, XvKv|
WªvdU cÖ`v‡bi m¤¢ve¨ ZvwiLt
Av‡e`b MÖnYKvixi ¯^vÿit Rvgvb‡Zi Wjvi D‡Ëvj‡bi Av‡e`bcÎ

c~e©vPj : 3 / 5 / 7.5 / 10 KvVv

K| Rvgvb‡Zi Wjvi †di‡Zi Rb¨ Av‡e`bKvixi Z_¨ t (Av‡e`bKvix KZ©„K c~iYxq)

(1) bvg t (K)................................................................................(L)..........................................................................................

(2) wcZv/¯^vgxi/ bvg t ...................................................................(L)gvZvi bvg..............................................................................
(3) Rvgvb‡Zi e¨vsK iwk`/GdwWwW bs/wUwU bs t.................................................ZvwiLt.............................................Bmy¨K…Z e¨vs‡Ki bvg
.................................................................†`k.........................................................(†iwgU¨vÝ msµvšÍ g~j iwk` mshy³ Ki‡Z n‡e)|
(4) Wjv‡ii cwigvb t (As‡K) ................................................(K_vq) ..............................................................................................
(5) Av‡e`bKvixi e¨vs‡Ki kvLvmn wnmve b¤^i t (†`kx/we‡`kx) ..............................................................................................................
(6) †hŠ_ Av‡e`bKvixMY GKK bv‡g †PK cÖvwßi †ÿ‡Î t mv`v KvM‡R ÿgZv Ac©Y cÎ Rgv w`‡Z n‡e|
(7) Av‡e`bKvixi WvK †hv‡M WªvdU †c‡Z B”QzK n‡j t c~Y© wVKvbv:............................................................................................................
(G †ÿ‡Î WvK PvR© KZ©b Kiv n‡e)
(8) †`kxq gy`ªvq WªvdU †c‡Z B”QzK n‡j t wnmve bs...................................e¨vsK...........................................kvLv.....................................
(9) ¯^vÿit (Av‡e`bc‡Îi Abyi~c 3wU) 1|..................................2|...................................3|................................Zvs .........................
L| G‡óU kvLv KZ©„K c~iYxq t (mwVK n‡j wUK √ w`b, mwVK bv n‡j X w`b)
(1) Av‡e`bKvixi mwVK mwVK wcZv/¯^vgx/gvZvi mwVK mwVK †iwgU¨Ý mwVK mwVK ¯^vÿi mwVK mwVK Qwe mwVK mwVK
bvg bq bvg bq msµvšÍ bq bq bq
iwk`
(2) †KvW bs...................................................
(3) Wjv‡ii cwigvb t (As‡K)...........................................(K_vq)......................................................................................................
(4) kvLvi gZvgZ t Rbve/ †eMg...................................................................................................................................................†K
......................................................................................................Wjvi/UvKv cÖ`v‡bi e¨e¯’v †bqv hvq|

........................................ .................................. ................................

wnmve mnKvix /wnmve iÿK mn-cwiPvjK (&G‡óU) Dc-cwiPvjK (G‡óU)
M| wnmve kvLvi KiYxq t
(1) wnmve kvLvi †iwRóªv‡i AšÍf~³ © c„ôv bs.......................... UvKvi cwigvY..............................................ZvwiLt.......................................
(2) Av‡e`bcÎ †cÖwiZe¨ e¨vs‡Ki bvg......................................................................kvLvi bvg..............................................................
(3) gZvgZ t Av‡e`bKvix Rvgvb‡Zi Wjvi Rgv nIqv wbwðZ mv‡c‡ÿ mswkøó e¨w³‡K wewa †gvZv‡eK PvR© KZ©b K‡i ivRD‡Ki wnmve
bs..................................................................................n‡Z Aewkó Wjv‡ii GKwU WªvdU †`qv hvq|

................................................... ............................... ..................................

wnmve mnKvix / wnmve iÿK (g~jab) mn.cwiPvjK (g~jab) Dc-cwiPvjK (wnmve)

N| e¨vsK KZ…©K c~iYxq t

(1) e¨vsK weeiYx‡Z Av‡e`b d‡g©i Wjvi AšÍf~©³ wK-bv nu¨v bv e¨vsK weeiYx‡Z Rvgvb‡Zi Wjvi AšÍf~³ wK-bv nu¨v bv
(2) Rbve/†eMg...................................................................wnmve bs-.............................................. e¨vsK........................................
..............................kvLv ............ ........................................ eive‡i ...................................... Wjvi n‡Z PvR© KZ©b K‡i ivRD‡Ki wnmve
bs....................................n‡Z Aewkó Wjvi Wªvd&U . bs ....................................... ZvwiL....................................†gvZv‡eK Bmy¨ Kiv n‡jv|

WªvdU MÖnYKvixi ¯^vÿi e¨vsK Kg©KZ©vi ¯^vÿi I mxj

(†PK MÖnYKvix Av‡e`bKvix bv n‡j †PK MÖn‡Yi ÿgZv AcY© cÎ mn Df‡qi Qwe mswkøó e¨vs‡K `vwLj Ki‡Z n‡e)