wf.AvB.

wc-1 ( webvg~‡j¨
wdm Rgv w`‡q e¨vsK iwm` GLv‡b
jvMv‡Z n‡e AvÂwjK cvm‡cvU©
Awdm ..............................................
Av‡e`b b¤^i ...............................
ZvwiL ....................
¯Œj b¤^i .....................................
MYcÖRvZš¿x evsjv‡`k miKvi
ewnivMgb I cvm‡cvU© Awa`ßi
XvKv |

cvm‡cv‡U©i Av‡e`b

Av‡e`bc‡Îi cÖ‡Z¨KwU Kjvg c~iY Ki‡Z n‡e| cÖ‡hvR¨ As‡k ÔwUK wPýÕ (ü) w`‡Z n‡e| AcÖ‡qvRbxq
As‡k ÔcÖ‡hvR¨ bqÕ gš—e¨ Ki‡Z n‡e|

cÖ_g Ask
c‡bi (15) eQ‡ii Kg eqmx c‡bi (15) eQ‡ii Kg eqmx
mš—v‡bi †¶‡Î gvZv, mš—v‡bi †¶‡Î gvZv,
wcZv wcZv
Av‡e`bKvixi GKwU Qwe A_ev ‰ea Awffve‡Ki A_ev ‰ea Awffve‡Ki
GKwU K‡i Qwe (3030 GKwU K‡i Qwe (3030
(4050 wgtwgt AvKv‡ii) | wgt wgt AvKv‡ii) AvVv wgt wgt AvKv‡ii) AvVv
AvVv w`‡q Gu‡U w`‡Z w`‡q Gu‡U w`‡q Gu‡U
w`‡Z n‡e w`‡Z n‡e
n‡e|

1| cy‡iv bvg ( WvK bvg mn, hw` _v‡K )

t.................................................................................................................
2| bvg ( Bs‡iRx‡Z eo A¶‡i )
t...........................................................................................................................
( cvm‡cv‡U© †hfv‡e †`L‡Z Pvb )
3| †fvUvi cwiwPwZ b¤^i ( hw` _v‡K )
t....................................................................................................................
4| †ckv ( Bs‡iRx‡Z )
t.......................................................................................................................................
5| Rb¥ ZvwiL t....................................................... 6| Rb¥¯’vb ( †Rjv )
t.............................................................
7| D”PZv t..........................................................
wgUvi.......................................................................†mw›UwgUvi
8| †Pv‡Li iO t....................................................... 9| Pz‡ji iO
t .......................................................................
10| mbv³Ki‡Yi Dc‡hvMx j¶Yxq we‡kl wPý
t...........................................................................................................
11| wcZvi bvg I bvMwiKZ¡ ( Bs‡iRx‡Z )
t................................................................................................................
12| wcZvi †ckv I †fvUvi cwiwPwZ b¤^i ( hw` _v‡K )
t.................................................................................................
13| gvZvi bvg I bvMwiKZ¡ ( Bs‡iRx‡Z )
t................................................................................................................
14| gvZvi †ckv I †fvUvi cwiwPwZ b¤^i ( hw` _v‡K )
t.................................................................................................
15| ¯^vgx/¯¿xi bvg I bvMwiKZ¡ ( cÖ‡hvR¨ †¶‡Î ) ( Bs‡iRx‡Z )
t.....................................................................................
( Av‡e`bKvix cyi“l n‡j ¯¿xi bvg Ges gwnjv n‡j ¯^vgxi bvg )
16| ˆea Awffve‡Ki bvg I bvMwiKZ¡ ( Bs‡iRx‡Z )
t...................................................................................................
17| ˆea Awffve‡Ki mv‡_
m¤úK© ..........................................................................................................................
18| Av‡e`bKvixi bvMwiKZ¡ t Rb¥m~‡Î ‰cwÎKm~‡Î †`kvš—i MÖn‡Yi
gva¨‡g Ab¨ †Kvbfv‡e
19| ˆeevwnK Ae¯’v t weevwnZ AweevwnZ weaev/wecZœxK
ZvjvKcÖvß
20| ¯’vqx wVKvbv ( Bs‡iRx‡Z ) t
MÖvg / evox / †ivW
t.........................................................................................................................................
WvKNi ( †KvW mn )
t......................................................................................................................................
_vbv t................................................................................ †Rjv
t.................................................................
21| eZ©gvb wVKvbv ( Bs‡iRx‡Z )
t...........................................................................................................................
MÖvg/ evox/ †ivW
t...........................................................................................................................................
WvKNi ( †KvW mn )
t......................................................................................................................................
Dc‡Rjv / _vbv t................................................................................ †Rjv
t...................................................
22| cÖvw_©©Z cvm‡cv‡U©i cvZv msL¨v t 48 cvZv 64 cvZv
-t 2 t -

23| wcZv / gvZv / ˆea Awffve‡Ki cvm‡cv‡U© Ab~aŸ© 12 eQi eqmx mš—v‡bi bvg Aš—fy©w³i †¶‡Î ( gvÎ
`yÕwU mš—vb ) t
Qwe Qwe
(1) (2)

†Q‡j †g‡q †Q‡j †g‡q

bvg t ........................................................ bvg t ............................................................

Rb¥ ZvwiL t ............................................... Rb¥ ZvwiL
t ...................................................
Rb¥¯’vb t ............................................... ... Rb¥¯’vb
t .......................................................

24| `k (10) eQi DËxY© / weKí / nviv‡bv / mgc©YK…Z ( mv‡iÛvi&W ) cvm‡cv‡U©i †¶‡Î t
K. c~‡e©i cvm‡cvU© b¤^i t ................................................. cÖ`v‡bi ZvwiL
t ............................................
cvm‡cv‡U©i †gqv` t .............................................. cÖ`v‡bi ¯’vb
t ..........................................................
L. nviv‡bvi †¶‡Î t wR. wW. b¤^i .......................... ZvwiL t ........................ _vbvi bvg
t ...................................... M. mgc©‡Yi †¶‡Î KviY
t...............................................................................................................................

wØZxq Ask (bevqb)

1. cvm‡cvU© b¤^i t ............................................. cÖ`v‡bi ¯’vb t ................................ ZvwiL

t .................................
2. †gqv` DËxY© nIqvi ZvwiL
t .............................................................................................................................
3. KZ eQ‡ii Rb¨ bevqb n‡e
t ............................................................................................................................
 Z…Zxq Ask (ms‡hvRb)

1. cvm‡cvU© b¤^i t .......................................... cÖ`v‡bi ¯’vb t ..................................... ZvwiL

t ...............................
2. cvm‡cv‡U© wbgœiƒc cwieZ©b cÖ‡qvRb t
K. bv‡gi evbvb t .......................................................................................................................... Gi
cwie‡Z©
..................................................................................................................................................... n‡e|
L. †ckv t ............................................................. Gi cwie‡Z© .............................................................
n‡e|
M. Rb¥ ZvwiL t ...................................................... Gi
cwie‡Z© ............................................................. n‡e|
N. wVKvbv t ................................................................................................................................. Gi
cwie‡Z©
...................................................................................................................................................... n‡e|
O. Ab¨vb¨ t.................................................................................................................................. Gi
cwie‡Z©
.................................................................................................................................................... n‡e|
3. we`¨gvb cvm‡cvU©- G Ab~aŸ© 12 eQi eqmx mš—v‡bi bvg ms‡hvRb (12 eQ‡ii Kg eqmx gvÎ
`yÕwU mš—v‡bi bvg hy³ Kiv hv‡e) t
Qwe Qwe
(1) (2)

†Q‡j †g‡q †Q‡j †g‡q

bvg t ........................................................ bvg t ............................................................

Rb¥ ZvwiL t ............................................... Rb¥ ZvwiL
t ....................................................
Rb¥¯’vb t ................................................... Rb¥¯’vb
t ........................................................

-t 3 t -

PZy_© Ask (AsMxKvi)

1| (K) Avwg kc_ K‡i ejwQ †h Av‡e`bc‡Î cÖ`Ë me Z_¨ mZ¨ Ges †Kvb wg_¨v Z_¨ w`‡q _vK‡j Avwg
AvBbZt `Ûbxq ne|
(L) Avwg BZtc~‡e© cvm‡cvU© MÖnY Kwiwb / K‡iwQ ( b¤^i ) t
..................................Kwiwb..........................................
cÖ`v‡bi ZvwiL t ................. c&ª‡hvR¨ bq.................... cÖ`v‡bi ¯’vb t ................... c&ª‡hvR¨
bq...........................
†gqv` DËxY© nIqvi ZvwiL
t .....................................................................................................................

2| Avwg Av‡iv cÖwZÁv KiwQ †h, †Kvb Kvi‡Y AfveMÖ¯— n‡q covq we‡`k †_‡K Avgv‡K A_ev
Avgvi †cvl¨‡K †`‡k cÖZ¨vevmb Kivi †¶‡Î hveZxq LiP cwi‡kv‡a Avwg eva¨ _vKe Ges we‡`‡k
Avgvi g„Zy¨ NU‡j gi‡`‡ni cwienb LiP Avgvi ˆea DËivwaKvix‡`i KvQ †_‡K Av`vq‡hvM¨ n‡e|
 ZvwiL t ................................. Av‡e`bKvixi ¯^v¶i ev
wUcmB
( Abc‡bq Kvwj‡Z )

cÂg Ask (mZ¨vqb)

Avgvi Ávb I wek¦vmg‡Z Dc‡i ewY©Z Z_¨ mZ¨ Ges

Av‡e`bKvix ................................................................. eQi hver
Avgvi cwiwPZ| wZwb Avgvi m¤§y‡L Av‡e`bc‡Î ¯^v¶i ev wUcmB K‡i‡Qb|

AvevwmK wVKvbv t ............................................................................. mZ¨vqbKvixi

c`exmn bvg I ¯^v¶i
.................................................................................................... ( mxj‡gvni w`‡Z n‡e )
†Uwj‡dvb b¤^i (hw` _v‡K) t ............................................................... ZvwiL
t ...............................

lô Ask (Awd‡m e¨env‡ii Rb¨)

Bmy¨K…Z cvm‡cvU© b¤^i t ............................................................ cvm‡cvU© MÖnYKvixi ¯^v¶i

t .............................................
cÖ`v‡bi ¯’vb t ....................................... ZvwiL t ................................ †gqv` DËxY© nIqvi ZvwiL
t ..................................
cvm‡cvU© ¯^v¶iKvix Kg©KZ©vi ¯^v¶i ( mxj‡gvnimn )
t .......................................................................................................
Av‡e`bKvixi cvm‡cvU© e¨envh© ¯^v¶i ev wUcmB (Abc‡bq Kvwj‡Z ) t

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

mßg Ask (Av‡e`bcÎ Rgvi iwm`)

AvÂwjK cvm‡cvU© Awdm t ...........................................................................

1| bw_ b¤^i t .............................................................. Rgvi ZvwiL
t ..................................................................
2| bw_i cÖKvi t Avš—R©vwZK we‡kl bZzb weKí bevqb
ms‡hvRb ms‡kvab
3| wd wn‡m‡e RgvK…Z UvKvi cwigvY
t ....................................................................................................................
4| cÖ`v‡bi ZvwiL
t ............................................................................................................................................

iwm` cÖ`vbKvixi c`exmn bvg I

¯^v¶i
( mxj†gvni w`‡Z n‡e )
 -t 4 t -
Av‡e`bcÎ c~iY I cvm‡cvU© cÖ`vb msµvš— mvaviY Z_¨vejx t

1| Av‡e`bKvix wba©vwiZ Av‡e`b dig A_ev Av‡e`b d‡g©i AweKj UvBc / mvB‡K¬v÷vBj /
d‡UvKwcK…Z d‡g©I Av‡e`b Ki‡Z cvi‡eb|
2| Av‡e`bKvix‡K Kvwj w`‡q Bs‡iRx A_ev evsjvq `yÕKwc Av‡e`bcÎ ( g~j ev d‡UvKwc ) c~iY Ki‡Z
n‡e|
3| Av‡e`bKvixi wZbwU cvm‡cvU© mvBR ( 4050 wgt wgt ) I GKwU ÷¨v¤ú mvBR (3030 wgt wgt )
Qwe `iKvi| GKwU K‡i
4050 wgt wgt AvKv‡ii Qwe `yÕwU Av‡e`bc‡Îi cÖwZwUi cÖ_g c„ôvi wbw`©ó ¯’v‡b jvMv‡Z
n‡e Ges Qwei Dc‡i mZ¨vqb Ki‡Z n‡e|
4| c‡bi (15) eQ‡ii Kg eqmx wkï‡`i c„_K cvm‡cv‡U©i †¶‡Î gv I evev `yÕR‡bi A_ev ˆea Awffve‡Ki
3030 wgt wgt AvKv‡ii `yÕwU Qwe Av‡e`bc‡Îi wbw`©ó RvqMvq jvMv‡Z n‡e Ges Qwei Dc‡i
mZ¨vqb Ki‡Z n‡e|
5| cÖ‡hvR¨ †¶‡Î †fvUvi AvB.wW. Kv‡W©i (hw` _v‡K), A_ev cÖvmw½K †UKwbK¨vj mb`mg~‡ni
( †hgb- Wv³vi, BwÄwbqvi, WªvBfvi BZ¨vw` ) mZ¨vwqZ d‡UvKwc `vwLj Ki‡Z n‡e|
6| bZzb cvm‡cv‡U© ev‡iv ( 12 ) eQ‡ii Kg eqmx mš—v‡bi bvg AšÍfz©w³i †¶‡Î Pvi Kwc 3030 wgt
wgt AvKv‡ii Qwe jvM‡e| `yÕwU di‡gB cÖwZR‡bi GKwU K‡i Qwe jvwM‡q Qwei Dc‡i mZ¨vqb
Ki‡Z n‡e I `yÕwU AwZwi³ Qwe w`‡Z n‡e (di‡gi 1g As‡ki 23 b¤^i Gw›Uª `ªóe¨)|
7| we`¨gvb cvm‡cv‡U© ev‡iv (12) eQ‡ii Kg eqmx mš—v‡bi bvg ms‡hvR‡bi †¶‡Î Pvi Kwc 3030
wgt wgt AvKv‡ii Qwe jvMv‡e| `yÕwU di‡gi cÖwZwU‡Z cÖwZR‡bi GKwU K‡i Qwe jvwM‡q
Qwei Dc‡i mZ¨vqb Ki‡Z n‡e Ges `yÕwU AwZwi³ Qwe Rgv w`‡Z n‡e (3q As‡ki 3 b¤^i Gw›Uª
`ªóe¨)|
8| ev‡iv ( 12 ) eQ‡ii Kg eqmx wkï‡`i †¶‡Î Av‡e`bc‡Îi 1g As‡ki 14, 15 I 16 b¤^i Gw›Uª c~iYc~e©K
wcZv A_ev gvZv A_ev ‰ea AwffveK ¯^v¶i Ki‡eb|
9| Av‡e`bc‡Îi 4_© Ask ( AsMxKvi ) Ges 6ô Ask- Gi wba©vwiZ ¯’v‡b Av‡e`bKvix‡K `yB ¯’v‡b
GKB ai‡Yi ¯^v¶i ev wUcmB w`‡Z n‡e| e‡·i wfZ‡ii ¯^v¶i ev wUcmBwU cvm‡cv‡U© jvMv‡bv
n‡e|
10| wbgœewY©Z e¨w³MY cvm‡cv†U©i Av‡e`cÎ I Qwe mZ¨vqb Ki‡Z cvi‡eb t (1) msm` m`m¨, (2)
wmwU K‡c©v‡ik‡bi †gqi, †WcywU
†gqi I KwgkbviMY, (3) †M‡R‡UW Kg©KZ©v, (4) wek¦we`¨vjq wk¶K, (5) †cŠimfv, Dc‡Rjv cwil`
I BDwbqb cwil‡`i
†Pqvig¨vbMY, (6) †emiKvix K‡j‡Ri wk¶K, (7) †emiKvix D”P we`¨vj‡qi cÖavb wk¶K, (8) ‰`wbK
cwÎKvi m¤úv`K, (9)
†cŠi KwgkbviMY, (10) ivóªvqË e¨vsK I ¯^vqZ¡kvwmZ ms¯’v ev K‡c©v‡ik‡bi bZzb RvZxq †eZb
†¯‹‡ji 7g I Z`~aŸ© †MÖ‡Wi
Kg©KZ©vMY|
11| Av‡e`b di‡g AvVv w`‡q jvMv‡bv Qwei Dc‡i Ggbfv‡e mZ¨vqb Ki‡Z n‡e hv‡Z mZ¨vqbKvixi
¯^v¶i I mxj‡gvni Qwei I
di‡gi wKQz Ask Ry‡o c‡o Ges GKB Kg©KZ©v Qwei Dc‡i I di‡gi 5g As‡k mZ¨vqb Ki‡eb|
12| bvg ms‡kva‡bi †¶‡Î Gm Gm wm ev mggv‡bi cix¶vi mb` A_ev cÖ_g †kªYxi g¨vwR‡÷ª‡Ui
Av`vj‡Zi njdbvgv (Gwd‡WwfU)
A_ev cwÎKvi weÁwß Avek¨K n‡e|
13| eqm ms‡kva‡bi †¶‡Î Gm Gm wm ev mggv‡bi cix¶vi mb` A_ev Rb¥mb` A_ev Rb¥ wbeÜxKiY
mb`cÎ Avek¨K n‡e|
14| †ckv cwieZ©‡bi †¶‡Î cwiewZ©Z †ckvi mc‡¶ mb` Avek¨K
n‡e|
15| ¯’vqx wVKvbv cwieZ©‡bi †¶‡Î †fvUvi ZvwjKv A_ev †fvUvi
cwiPqcÎ A_ev 10 bs Aby‡”Q‡` ZvwjKvfy³ e¨w³eM© KZ„©K
cÖ`Ë mb` A_ev cwiewZ©Z wVKvbv m¤ú‡K© †h †Kvb wbf©i‡hvM¨ cÖgvY Avek¨K n‡e|
16| mš—v‡bi bvg ms‡hvR‡bi †¶‡Î D³ mš—v‡bi Rb¥ mb` Av‡e`bc‡Îi mv‡_ `vwLj Ki‡Z n‡e|
17| bZzb cvm‡cvU© cÖ`v‡bi mgqmxgv t
K. AwZ Riyix t evnvËi (72) N›Uvi g‡a¨ cywjk cÖwZ‡e`b cvIqv bv †M‡jI cvm‡cvU© cÖ`vb Kiv
n‡e| weiƒc cÖwZ‡e`b cvIqv †M‡j AvBbMZ e¨e¯’v †bqv n‡e|
 L. Ri“ix t †fvUvi AvBwW Kv©W _vK‡j ev cywjk cªwZ‡e`b cvIqv †M‡j GMvi (11) w`b c‡i,
Ab¨_vq GKzk ( 21 ) w`b c‡i cvm‡cvU© cÖ`vb Kiv n‡e| weiƒc cÖwZ‡e`b cvIqv †M‡j
AvBbMZ e¨e¯’v †bqv n‡e|
M. mvaviY t †fvUvi AvBwW KvW© _vK‡j ev cywjk cÖwZ‡e`b cvIqv †M‡j GKzk (21) w`b c‡i
Ab¨_vq wÎk (30) w`b ci cvm‡cvU© cÖ`vb Kiv n‡e| weiƒc cÖwZ‡e`b cvIqv †M‡j AvBbMZ
e¨e¯’v †bqv n‡e|
18| RgvK…Z cvm‡cv‡U©i cwie‡Z© hvwPZ bZzb, weKí, bevqb, ms‡hvRb BZ¨vw` †¶‡Î Ri“ix wd
cª`vb Ki‡j evnvËi (72) N›Uvi g‡a¨ Ges mvaviY wd cÖ`vb Ki‡j mvZ (7) Kg©w`e‡mi g‡a¨ Zv cÖ`vb
Kiv n‡e|
evsjv‡`k miKv‡ii B-wmwU‡Rb mvwf©m Gwc‡Kkb †_‡K Download site: http://www.forms.gov.bd
gyw`ªZ