RbZv e¨vsK wjwg‡UW

................................ kvLv
wnmve †Lvjvi dig wnmveavixi
¯’vqx AvvgvbZ/mÂqx w¯‹g/we‡kl w¯‹g wnmve Qwe

ZvwiL : ......................

e¨e¯’vcK wnmve b¤^e: ............................................

RbZv e¨vsK wjwg‡UW BDwbK MÖvnK AvBwW †KvW: .........................
......................................kvLv| (e¨vs‡Ki e¨env‡ii Rb¨)

wcÖq g‡nv`q,
Avwg/Avgiv Avcbvi kvLvq GKwU wnmve †Lvjvi Rb¨ Av‡e`b KiwQ| Avgvi/Avgv‡`i wnmve msµvšÍ I e¨w³MZ we¯ÍvwiZ
Z_¨ wb‡¤œ cÖ`vb KiwQ:
| cÖ_g Ask: wnmve msµvšÍ Z_¨vw`|
1| wnmv‡ei wk‡ivbvg (evsjvq) :.................................................................................................
In English (Block Letter) :.................................................................................................
2| K) ¯’vqx AvgvbZ Gi †ÿ‡Î cÖ‡hvR¨ :
cwigvY: (As‡K) .......................(K_vq).........................................(my`/gybvdvi nvi) .............
†gqv`Kvj : eQi gvm w`b| †gqv` c~wZ©i ZvwiL: .................................................
bevq‡bi †ÿ‡Î : Avmj Ges my` bevqb Kiæb
ïaygvÎ Avmj bevqb Kiæb, my` ..............................b¤^i wnmv‡e Rgv Kiæb|
cÖ‡hvR¨ b‡n|
L) mÂqx w¯‹g/we‡kl w¯‹g Gi †ÿ‡Î cÖ‡hvR¨:
w¯‹‡gi bvg : .............................................w¯‹‡gi †gqv` :..........................
MÖvnK KZ©„K cÖ‡`q wKw¯Íi wd«‡Kv‡qwÝ : ................................. wKw¯Íi msL¨v : ....................................
wKw¯Íi cwigvY : (As‡K) .......................(K_vq)...............................................
†gqv`v‡šÍ e¨vsK KZ©„K cÖ‡`q : (As‡K) .......................(K_vq)...............................................
GKKvjxb Rgv : (As‡K) .......................(K_vq)...............................................
cwi‡kv‡ai wd«‡Kv‡qwÝ :............................... cwi‡kva¨ wKw¯Íi msL¨v : ..........................
e¨vsK KZ©„K cÖwZ wKw¯Í‡Z cÖ‡`q : (As‡K)....................... (K_vq)................................................
3| wnmve cwiPvjbv c×wZ (wUK w`b) : GKKfv‡e †hŠ_fv‡e †h †Kvb GKRb
†h †Kvb GKRb A_ev RxweZRb Ab¨vb¨..............................
| wØZxq Ask: cÖwZôvb msµvšÍ Z_¨vw`|
1| cÖwZôv‡bi bvg (evsjvq) :...............................................................................................................
In English (Block Letter) : ....................................................................................................
2| ‡UªW jvB‡mÝ b¤^i :...................................ZvwiL : .....................Bmy¨Kvix KZ©„cÿ: ...................................
3| wbeÜb b¤^i :...................................... ZvwiL : ......................wbeÜb KZ©„cÿ I †`k:......................
wbeÜbK…Z wVKvbv: .............................................................................................................................
4| f¨vU †iwR‡÷ªkb b¤^i/BIN :.................................................................................................................
5| U¨v· AvBwW b¤^i (TIN) (hw` _v‡K) :.....................................................................................................
6| e¨emv¯’j/Awd‡mi wVKvbv :...................................................................................................................
‡gvU 3 c„ôvi g‡a¨ 1 bs c„ôv
7| cÖwZôv‡bi aiY (wUK w`b) : GKK gvwjKvbv Askx`vix †hŠ_ D‡`¨vM cÖvB‡fU wj: †Kv¤úvbx
cvewjK wj: †Kv¤úvbx Uªv÷ GbwRI/GbwcI K¬ve/‡mvmvBwU
wkÿv cÖwZôvb agx©q cÖwZôvb Ab¨vb¨ (wbw`©ófv‡e D‡jøL Kiæb) .............
8| e¨emvi aiY : †UªwWs †mev Drcv`b Ab¨vb¨ (wbw`©ófv‡e D‡jøL Kiæb) ..........
9| e¨emv‡qi cÖK…wZ (we¯ÍvwiZ) : ...............................................................................................................
10| evwl©K Uvb©Ifvi : .............................................................................................................................

| Z…Zxq Ask: e¨w³ msµvšÍ Z_¨vw`1|

1| wnmveavixi/cwiPvjbvKvixi bvg (evsjvq) :...........................................................................................

In English (Block Letter) :.......................................................................................................
2| Rb¥ ZvwiL :.......................................................................................................
3| wcZvi bvg :.......................................................................................................
In English (Block Letter) :.......................................................................................................
4| gvZvi bvg :.......................................................................................................
In English (Block Letter) :.......................................................................................................
5| ¯^vgx/¯¿xi bvg :.......................................................................................................
In English (Block Letter) :.......................................................................................................
6| RvZxqZv :.......................................... 7| wj½ (wUK w`b): cyiæl gwnjv Z„Zxq wj½|
(wnmveavix we‡`kx bvMwiK n‡j wfmvmn cvm‡cv‡U©i Kwc Avewk¨Kfv‡e MÖnY Ki‡Z n‡e)
8| †iwm‡W›U ÷¨vUvm (wUK w`b): †iwm‡W›U bb-‡iwm‡W›U
(cÖ‡qvRbxq †ÿ‡Î e¨vsK KZ©„K MvBWjvBÝ di d‡ib G·‡PÄ Uªvb‡RKkbm& Gi wb‡`©kbv AbymiY Ki‡Z n‡e)
9| †ckv (we¯ÍvwiZ) : ....................................................................................................................
10| gvwmK Avq : ....................................................................................................................
11| A‡_©i Drm (we¯ÍvwiZ) : .....................................................................................................................
12| U¨v· AvBwW b¤^i (TIN) (hw` _v‡K) : ...................................................................................................
13| (K) eZ©gvb wVKvbv : moK/MÖvg:...................... †cv:......................... _vbv: ..........................................
‡Rjv:........................ †dvb/‡gvevBj b¤^i:............................. B‡gBj:.........................................
(L) ¯’vqx wVKvbv : moK/MÖvg:........................ †cv:......................... _vbv: ...................................
‡Rjv:........................ †dvb/‡gvevBj b¤^i:............................. B‡gBj:.........................................

14| cwiwPwZ cÎ : RvZxq cwiPqcÎ b¤^i/cvm‡cvU© b¤^i/Rb¥ wbeÜb b¤^i: ..........................................................

15| cwiPq`vbKvixi Z_¨ (RvZxq cwiPqcÎ e¨ZxZ Ab¨vb¨ cwiwPwZcÎ cÖ`v‡bi †ÿ‡Î) :

(K) bvg: .............................................(L) wnmve/RvZxq cwiPqcÎ b¤^i (Rb¥ ZvwiLmn): .........................

¯^vÿi (ZvwiLmn) : .........................................................................................................................

16| wnmveavix bvevjK n‡j :

Avwg wb¤œewY©Z wnmveavixi •ea AwffveK wn‡m‡e GB g‡g© †NvlYv KiwQ ‡h, wnmveavix bvevjK| Zvi cÖ‡qvRbxq Z_¨
mshy³ di‡g cÖ`vb Kiv n‡jv| wnmveavix mvevjK bv nIqv ch©šÍ wKsev Avgvi cieZ©x †NvlYv bv †`qv ch©šÍ AwffveK
wnmv‡e wnmvewU Avgvi ¯^vÿ‡i cwiPvwjZ n‡e (AwffveK ej‡Z evev A_ev gv A_ev Df‡qi AeZ©gv‡b Ab¨ †Kvb AvBbMZ
AwffveK‡K eySv‡e)|
(K) Awffve‡Ki bvg : ............................................................ bvevj‡Ki mv‡_ m¤úK© : ................................

1 wnmveavix GKvwaK n‡j cÖ‡Z¨‡Ki Ges wnmveavix bvevjK n‡j wnmveavixi AwffveK (evev A_ev gv A_ev Ab¨ †Kvb AvBbMZ AwffveK) Gi e¨w³ msµvšÍ
Z_¨vw` c„_Kfv‡e Z„Zxq As‡k ev Z…Zxq As‡ki msjMœx wn‡m‡e hy³ Ki‡Z n‡e|
‡gvU 3 c„ôvi g‡a¨ 2 bs c„ôv
 | PZz_© Ask: bwgwb msµvšÍ Z_¨vw`2|

1| bwgwb msµvšÍ Z_¨vejx :

Avwg/Avgiv G wnmv‡ei A_© Avgvi/Avgv‡`i g„Zz¨i ci wb‡¤œ ewY©Z e¨w³/e¨w³MY‡K cÖ`v‡bi Rb¨ g‡bvbxZ Kijvg|
Avwg/Avgiv DwjøwLZ g‡bvbqb †h †Kvb mgq evwZj ev cwieZ©‡bi AwaKvi msiÿY Kwi| Avwg/Avgiv GB g‡g© Av‡iv m¤§wZ
Ávcb KiwQ †h, Avgvi/Avgv‡`i G wb‡`©kbv †gvZv‡eK e¨vsK A_© cÖ`vb Ki‡e Ges A_© cwi‡kva Kiv n‡j mswkøó AvgvbZ
m¤úwK©Z hveZxq `vq cwi‡kva n‡q‡Q e‡j MY¨ n‡e|

K) bwgwbi bvg I Rb¥ ZvwiL : .................................................................................. wnmveavix KZ©„K

mZ¨vwqZ bwgwbi
L) wVKvbv : ..................................................................................
Qwe
M) kZKiv nvi : ..................................................................................
N) wnmveavixi mv‡_ m¤úK© : ..................................................................................
O) RvZxq cwiPqcÎ b¤^i/cvm‡cvU© b¤^i/Rb¥ wbeÜb b¤^i/Ab¨vb¨ (wbw`©ófv‡e D‡jøL Ki‡Z n‡e) :...............................
2| bwgwb bvevjK n‡j Zvi/Zv‡`i bvevjK _vKv Ae¯’vq wnmveavix/wnmveavixM‡Yi g„Zz¨i †ÿ‡Î e¨vsK †Kv¤úvbx AvBb,
1991 Gi 103 (2) aviv Abyhvqx bwgwbi c‡ÿ Avgvb‡Zi A_© MÖnYKvixi Z_¨ :
K) bvg : ..........................................................................................................................
L) ¯’vqx wVKvbv : ..........................................................................................................................
M) RvZxq cwiPqcÎ b¤^i/cvm‡cvU© b¤^i/Rb¥ wbeÜb b¤^i/Ab¨vb¨ (wbw`©ófv‡e D‡jøL Ki‡Z n‡e) :...............................
N) bwgwbi mv‡_ m¤úK© : .........................................................................................................................

| ‡NvlYv I ¯^vÿi|
Avwg/Avgiv mÁv‡b †NvlYv KiwQ †h, DwjøwLZ Z_¨vw` mZ¨| Avwg/Avgiv e¨vs‡Ki Pvwn`v †gvZv‡eK cÖ‡qvRbxq Z_¨/`wjjvw`
mieivn Kie|

Av‡e`bKvix (MY)3 Gi bvg, ¯^vÿi I ZvwiL :

1| .................................. 2| ....................................3| .................................. 4| ..............................

| e¨vs‡Ki e¨env‡ii Rb¨|

gšÍe¨ : .................................................................................................................................................

.............................. ..............................
.............................. ..............................
wnmve †Lvjvi mv‡_ mswkøó Kg©KZ©vi Aby‡gv`bKvix Kg©KZ©vi
bvghy³ mxjmn ¯^vÿi I ZvwiL bvghy³ mxjmn ¯^vÿi I ZvwiL

2 bwgwb GKvwaK n‡j cÖ‡Z¨‡Ki bwgwb msµvšÍ Z_¨vw` PZz_© As‡k ev PZz_© As‡ki msjMœx wn‡m‡e hy³ Ki‡Z n‡e|
3 wnmveavix bvevjK n‡j Av‡e`bKvixi ¯^vÿ‡ii ¯’‡j wnmveavixi AwffveK ¯^vÿi Ki‡eb|
‡gvU 3 c„ôvi g‡a¨ 3 bs c„ôv