K¨v›Ub‡g›U †evW©, XvKv Qwe

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e¨w³MZ Z_¨
BDRvi bvg t .............................................................................................................................

AvevwmK A_ev A¯’vqx cwiPq c‡Îi Rb¨ wm‡j± Kiæb t AvevwmK A¯’vqx

bZzb/bevqb (*) t bZzb bevqb

Av‡e`bKvixi bvg (evsjv) t .............................................................................................................................

Av‡e`bKvixi †ckv t .............................................................................................................................

Kg©¯’‡ji wVKvbv t .............................................................................................................................

wcZvi bvg t .............................................................................................................................

gvZvi bvg t .............................................................................................................................

¯^vgx/¯¿x bvg t .............................................................................................................................

†dvb b¤^i t .............................................................................................................................

B‡gBj t .............................................................................................................................

Rb¥ ZvwiL t ............/........./.........................

mb³iY wPý t .............................................................................................................................

Av‡e`bKvixi GbAvBwW/Rb¥wbeÜb bs t .............................................................................................................................

eZ©gvb wVKvbv t d¬vU bs..................................evox bs...................................‡ivW bs............................

GjvKv ....................................................................................................................

¯’vqx wVKvbv t .............................................................................................................................

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evoxi gvwjKvbv/ fvovwUqvi Z_¨

emev‡mi aiY (*) t evoxi gvwjK fvovwUqv miKvix evmv

evmv/evoxi gvwj‡Ki bvg t .............................................................................................................................

evox fvovi Pzw³i †gqv` t ......../......../........................... †_‡K ......../......../...........................

 cÖZ¨qbKvix Kg©KZ©v
(†mbvwbev‡mi Af¨šÍ‡i Kg©iZ)

cÖZ¨vqb Kg©KZ©v t mvgwiK AmvgwiK

cÖZ¨vqbKvix Kg©KZ©vi bvg t ........................................................................................................................

c`ex t ........................................................................................................................

Kg©¯’‡ji wVKvbv t ........................................................................................................................

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cÖZ¨vbKvix Kg©KZ©vi †gvevBj bs t ........................................................................................................................

†NvlYv I ¯^vÿi
Av‡e`bKvixi kc_ t Avgvi †`Iqv weeiY mZ¨| hw` wg_¨v cÖgvwbZ nq, Z‡e AvBb `Ðbxq Aciva n‡e|

¯^vÿi t ........................................................................................................................

Av‡e`‡bi di‡gi mv‡_ wb‡¤œ cÖ‡qvRbxq KvMRcÎ mshy³ Ki‡Z n‡et

1. Av‡e`bKvixi Qwe
2. Av‡e`bKvixi GbAvBwWi/Rb¥wbeÜb Kwc
3. ¯’vqx wVKvbvi ¯^c‡¶ mswkó IqvW© Kwgkbvi / BD wc ‡Pqvig¨vb KZ©…K c«`Ë bvMwiK mb`
4. evoxi gvwj‡Ki GbAvBwWi d‡UvKwc
5. evoxi gvwj‡Ki mv‡_ m¤ú©‡Ki cÖgvb cÎ
6. evox fvovi Pyw³cÎ
7. †h ‡Kvb BEwUwjwU we‡ji Kwc cvwb/M¨vm/ we`¨yr /‡Uwj‡dvb
8. cÖZ¨vqbKvixi GbAvBwW/PvKyixi cwiPqc‡Îi d‡UvKwc
9. cÖZ¨vqbKvix Kg©KZ©v cÖZ¨vqb cÎ
10. bevq‡bi †ÿ‡Î cyivZb Kv‡W©i d‡UvKwc
11. ¯^v¶i
 cÖZ¨qbcÎ
G g‡g© cÖZ¨qb Kiv hv‡”Q †h, Rbve/‡eMg : .........................................................................
.................................... wcZv: .....................................................................................,
gvZv: ............................................................................ eZ©gvb wVKvbv: ............................
...................................................................................................................................
¯’vqx wVKvbv: ....................................................................................................................
.....................................................................................................................................
e¨w³MZfv‡e Avgvi cwiwPZ| Zv‡K XvKv †mbvwbev‡m cÖ‡e‡ki Rb¨ ¯’vqx/A¯’vqx cwiPqcÎ cÖ`v‡bi Rb¨
mycvwik KiwQ|

ZvwiLt cÖZ¨qbKvix Kg©KZ©vi bvghy³ wmjmn ¯^vÿi

 M„nKg©x/WªvBfvi/wmwKDwiwU
cÖZ¨qbcÎ

G g‡g© cÖZ¨qb Kiv hv‡”Q †h, Rbve/‡eMg: ..............................................................................

wcZv: ............................................................ gvZv: ........................................................

¯’vqx wVKvbv: ....................................................................................................................

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eZ©gvb wVKvbv: evox# ......................, d¬¨vU# .............................., †ivW# ...............................

GjvKv: ...........................................................................................................................

Avgvi evmvq M„nKg©x/WªvBfvi/wmwKDwiwU wn‡m‡e Kg©iZ Av‡Qb|

¯^vÿi:

evoxi gvwjK/eivÏjvfKvixi bvg:

‡dvb b¤^i:
GbAvBwW/Rb¥ wbeÜb b¤^i:
wVKvbv:

ZvwiL: