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

eivei,
Dc‡Rjv wkÿv Awdmvi
Dc‡Rjv: ........................, †Rjv: ............................

welqt cÖv_wgK wkÿv mgvcbx mb‡` bvg / wcZvi bvg / gvZvi bvg / Rb¥ ZvwiL ms‡kvab cÖm‡½|

g‡nv`q,
h_vwenxZ m¤§vb c~e©K webxZ wb‡e`b GB †h, Avwg .......................................................................................,
wcZv : ............................................................. gvZv : .......................................................................,
we`¨vjq : ...................................................................................... †ivj bs-........................................,
20 .......... m‡b cÖv_wgK wkÿv mgvcbx cixÿvq DËxY© n‡qwQ| cixÿvi †iKW©c‡Î Avgvi bvg / wcZvi bvg / gvZvi bvg
/ Rb¥ ZvwiL fzj nIqvq ms‡kva‡bi Rb¨ Av‡e`b KiwQ| Avcbvi m`q we‡ePbvi Rb¨ cÖ‡qvRbxq Z_¨ wb‡¤œ †ck Kiv
nj|
µ: bs weeiY ‡iKW©c‡Îi Z_¨ mwVK Z_¨
01 bvg
02 wcZvi bvg
03 gvZvi bvg
04 Rb¥ ZvwiL

AZGe, g‡nv`‡qi wbKU webxZ cÖv_©bv ewY©Z Z_¨vw`i Av‡jv‡K Avgvi †iKW©cÎ ms‡kva‡bi e¨e¯’v MÖnY Ki‡Z Avcbvi
m`q gwR© Kvgbv KiwQ|

webxZ wb‡e`K-

Av‡e`bKvixi ¯^vÿi t ........................................

Av‡e`bKvixi bvg t ........................................

fz‡ji KviY e¨vL¨vmn cÖwZôvb cÖav‡bi mycvwikt ...........................................................................................

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

¯^vÿi I mxj
mshyw³-
1. Rb¥ wbe܇bi AbjvBb Kwc - 1 Kwc
2. wcZvi RvZxq cwiPqcÎ Kwc - 1 Kwc
3. gvZvi RvZxq cwiPqcÎ Kwc - 1 Kwc
4. cÖv_wgK wkÿv mgvcbx mb‡`i Kwc - (g~j Kwc)