iwoZ esa tkjhdÙkkZ cSad dk uke : ____________________________________________

iwoZ eas lefiZr cSad Mªk¶V la[;k ,oa fnukad : ___________________________________________

jkf”k ¼:Û½ : ___________________________________________

iwoZ esa fd;s x;s vkosfnr in dk uke____________________________________________________

osru Lrj _____________ foKkiu la[;k. ____________ Øe la0._______________________

tkjhdÙkkZ cSad dk uke : _____________________________

cSad Mªk¶V la[;k ,oa fnukad : ___________________________

jkf”k ¼:Û½ : ___________________________

vkosfnr in dk uke_________________________________________________________________
osru Lrj _____________ foKkiu la[;k. ____________ Øe la0.________ ______________
1. iwjk uke (fgUnh esa) _______________________________________________________________

2. iwjk uke (vaxzsth esa cMsa v{kjksa) ______________________________________________________

3. firk@ifr dk uke ______________________________________________________________

4. ekrk dk uke __________________________________________________________________

5. ¼d½ iwjk irk (LFkk;h) ____________________________________________________________

 _____________________________________________________________________________

_____________________________________________________________________________

ftyk_______________________________ fiu dksM __________________________________

¼[k½ oÙkZeku irk (i=kpkj) _________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

ftyk_________________fiu dksM_________________eksckbZy la[;k______________________

6. vk/kkj la[;k _____________________________ bZesy ___________________________________

7. tUe frfFk _______________________________________________________________________

8. vkosnd dk jk’Vªh;rk ____________________________ fyax________________________________
9. vuqÛtkfr@vuqÛtu tkfr@vÛfiÛoxZ@ ________________________________________________
fiÛoxZ@fiÛoxksZ dh efgyk@vukÛ oxZ@vkfFkZd :Ik ls detksj oxZ vafdr djsAa *

[*vuqÛtkfr&vuqlwfpr tkfr] vuqÛtu tkfr&vuqlwfpr tutkfr]vÛfiÛoxZ&vR;ar fiNM+k oxZ]fiÛoxZ&fiNM+k

oxZ] fiÛoxksZ dh efgyk&fiNMs oxksZ dh efgyk ,oa vukÛ oxZ&vukjf{kr oxZ]

10. ekr`Hkk’kk ________________________________________________________________________

11. LFkk;h fuokl LFkku ds jkT; dk uke __________________________________________________

12. “kS{kf.kd ;ksX;rk %&

ØÛ ijh{kk mÙkh.kZ o’kZ cksMZ@laLFkku@fo'ofo|ky; dk uke Js.kh izkIrkad dk izfr'kr@ fo’k;
laÛ lhÛthÛihÛ,Û@
vksÛthÛihÛ,Û
13. fiNys jkstxkj dh lwpukA
ØÛ inuke ,oa osrueku fu;ksDrk dk uke vof/k dc ls dc vafre osru ,oa HkÙkk in NksM+us dk dkj.k
laÛ rd

14. izek.k&i= ,oa vuqyXudksa dh lwph vafdr djsAa

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

15. nks O;fDr;ksa dk uke ,oa irk tks vkosnd dk lac/a kh ugha gks] ysfdu vkosnd dks tkurs gksAa

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

’k
eSa ?kks’k.kk djrk@djrh gw¡ fd bl QWkeZ esa tks Hkh lwpuk esjs }kjk Hkjh xbZ gS og lR; ,oa lgh gSA ;fn
dksbZ lwpuk xyr ;k vlR; ikbZ tkrh gS rks bls jn~n dj fn;k tk;] lkFk gh esjk@esjh mEehnokjh ,oa
fu;qfDr dks Hkh cxSj lwpuk ds v;ksX; ?kksf’kr dj fn;k tk;A

LFkku %-----------------------------------
fnukad % -------------------------------- vkosnd dk gLrk{kj-
 ¼dsoy ljdkjh lsod ds fy,½

vkosnd Jh@Jhefr@lqJh@MkWÛ ------------------------------------------------------------------ LFkk;h@vLFkk;h ----------------------------------

- in ¼inuke½ esa :i;s osru Lrj ---------------------------- vof/k --------------------------------- ls ------------------------------------ rd dk;Zjr

gSA mudk ewy osru ------------------------------ :i;s gSA

------------------------------------------------------------------ ¼vkosnd@vkosfndk dk uke½ dk vkosnu vxzlkfjr dj fn;k tkrk

gS vkSj ;fn vkosfnr in ds fy, mudk p;u gks tkrk gS rks mls dk;ZeqDr dj fn;k tk;sxkA

LFkku %-----------------------------------
fnukad % --------------------------------
gLrk{kj-
vf/kdkjh dk inuke
¼vf/kdkfjd eqgj ds lkFk½