1

fgekpy x`g.kh lqfo/kk ;kstuk हेतु KYC QkeZ

____________
(dkyh L;kgh }kjk cM+s v{kjksa esa Hkjk tkuk gS lHkh QhYM Hkjuk vfuok;Z gSA)
(For Instructions to fill from please see overleaf) uohure ikliksVZ
1.) miHkksäk fooj.k lkbZt
(Jh@Jherh@dqekjh) * :______________________________________ QksVks fpidka,
uke * :______________________________________
d) vk/kkj uacj [k ) tUe frfFk *
D D M M Y Y Y Y
x) utnhdh fj'rsnkj
firk dk uke* :_____________________ ekrk dk uke *
:_____________________
2.) jlksbZ xSl dusD'ku ds fy, irk @ laidZ tkudkjh
irk dk çek.k ihvks, Js.kh dksM *
:______________________________________
P 0 A

iksLV v‚fQl@xk¡o@okMZ@rglhy * :____________________________________

____________________________________
ftyk * :__________fiu dksM *__________jkT; *________________

eksckby uacj bZesy Id* ___________________________________

3.) vU; çklafxd fooj.k

POI Js.kh dksM * P 0 I :____________________________________ dkMZ uacj * :____________________________________
[k) ;fn miyC/k gks rks jk'ku dkMZ dk fooj.k
jkT; dk uke :________________________________ jk'ku dkMZ la[;k H P – –

4.) Js.kh
vuqlwfpr tkfr vuqlwfpr tutkfr vU; fiNMk oxZ lkekU;
5.) jk"Vªh;rk
Hkkjrh; frCcrh
6.) jk'ku dkMZ Js.kh
xjhch js[kk ls mij xjhch js[kk ls uhps vUrksn; vUu ;kstuk izkFkfed ifjokj vUuiw.kkZ
(APL) (BPL) (AAY) (PH) (ANA)

7.) cSad [kkrs dk fooj.k

cSad खाता सं या :____________________________________ cSad dk uke :____________________________________
'kk[kk dk uke :______________________________________ IFSC dksM :____________________________________
?kks"k.kk :- eSa iqf"V djrk gwW@ djrh gwW fd tks tkudkjh esjs }kjk miyC/k djokbZ xgZ gS oks esjs Kku o fo’okl ds vuqlkj lgh gSA ;fn esjs }kjk miyC/k djokbZ
xbZ tkudkjh tkudkjh >wBh@ v/kqjh ikbZ tkrh gS rks ljdkjh ds fofu;eu dh mYya?ku djus dh fLFkfr esa LPG, IOC/BPC/HPC dks eq>s flys.Mjksa dh vkiwfrZ can djus
dk iw.kZ vf/kdkj gS çfrHkwfr tek dh tCrh vkSj naM ds vkjksiksa ds vuqlkj çfrHkwfr uhfr vkSj fn'kkfunsZ'k vkSj çko/kku ds rgr ykxw dkuwuh dkjZokbZ 'kq: dj ldrs gSaA

( )
________________ frfFk :
D D M M Y Y Y Y
uke vkSj gLrk{kj *
Mhyj @ forjd }kjk Hkjk tk,
es iqf"V djrk gqW fd mijksdr nLrkostks dh çfr;ks dks mudh ewy çfr ls lR;kfir dj fy;k x;k gS
miHkksäk la[;k(;fn vkoafVr gks ):

frfFk :
forjd ds gLrk{kj D D M M Y Y Y Y

.............................................................................................................................
jlhn
eSa iqf"V djrk gwW@ djrh gwW dh mijksDr ds0okbZ0lh0 esa Hkjh xbZ tkjdkjh esjs vuqlkj lgh gSA
uke__________________________________miHkksäk la[;k(;fn vkoafVr gks ):____________________________________

You can download from epds.co.in admis.hp.nic.in/ehimapurti gLrk{kj vkSj forjd ds eqgj
 2
dsokbZlh QkeZ Hkjus ds fy, funsZ'k
* ds lkFk fpfàr QhYM vfuok;Z gSa vkSj O;fä dks dsokbZlh çLrqr djus ds fy, mls Hkjuk gksxk
1 d) नाम igpku iz= ds vk/kkj ij uke ntZ djsaA

[k) lacaf/kr fj'rsnkj ds foLrkj firk ;k ifr dk uke vfuok;Z gS%& fpfUgr djs A

2) irs dk çek.k POA uhps fn, x, nLrkostksa esa ls fdlh ,d nLrkost dks layXu djs vkSj QkeZ esa Js.kh dk fooj.k
nsaA dkWye esa Hkjh xbZ tkudkjh ih0vks0,0 ds vuqlkj gh gksuh pkfg,A tks nLrkost QkeZ ds
lkFk layXu fd;k tk jgk gS mldh iqf"V gsrq ewy izfr forjd dks fn[kka,A
nLrkostksa dh lwph Js.kh dksM
vk/kkj dkMZ (UID) ih0vks0,001
Mªkbfoax fyllsal

ih0vks0,002

yht djkj

ih0vks0,003

ernkrk igpku i=
ih0vks0,004

VsyhQksu fctyh ikuh dk fcy

ih0vks0,005

ikliksVZ

ih0vks0,006

Lo&?kks"k.kk ,d jktif=r vf/kdkjh }kjk çekf.kr ih0vks0,007
jk'ku dkMZ

ih0vks0,008

¶ySV vkoaVu dCtk i=
ih0vks0,009
vkokl iathdj.k nLrkost
ih0vks0,010
LIC ikfylh
ih0vks0,011

cSad ØsfMV dkMZ LVsVesaV
ih0vks0,012

3 d) igpku ds çek.k (POI) uhps fn, x, nLrkostksa esa ls fdlh ,d nLrkost dks layXu djs vkSj QkeZ esa Js.kh dk fooj.k
nsaA miHkksDrk }kjk tks nLrkost QkeZ ds lkFk layXu fd;k tk jgk gS mldh iqf"V gsrq ewy izfr
forjd dks fn[kka,A

nLrkostksa dh lwph Js.kh dksM

k/kkj
v dkMZ (UID/EID)

ih0vks0bZ0 01

ikliksVZ uacj ih0vks0bZ0 02

AN
P dkMZ uacj ih0vks0bZ0 03

ernkrk igpku i= ih0vks0bZ0 04
bZn dkMZ b'kw lsaVªy @ LVsV ih0vks0bZ0 05



ªkbfoax
M fyllsal ih0vks0bZ0 06
 fgekpy x`fg.kh lqfo/kk ;kstuk gsrq fu/kkZfjr vkosnu i=
lsok esa
1-lfpo] xzke ipak;r]
_____________________________
2-vk;qDr@ dk;Zdkjh vf/kdkjh]
uxj fuxe____________________
3-lfpo@dk;Zdkjh vf/kdkjh]
uxj lfefr@ifj”kn_______________
4-lfpo@ dk;Zdkjh vf/kdkjh]
vf/klwfpr {ks= ifj”kn@uxj ipak;r_________
5-lfpo] dSuVksueSV cksMZ_________________

¼tks ykxw gks fVd djsa½

fo"k; %
fgekpy x`fg.kh lqfo/kk ;kstuk ds vUrxZr ?kjsyw ,y0ih0th0

dquSD'ku ds fy, vkosnu i= A
egksn;]

eS------------------------------ iRuh @lqiq=h @ Lkqiq= ------------------------------
vk/kkj la[;k----------------------------------------] fMthVy jk'ku dkMZ la[;k% ---------------------------
LFkkbZ fuoklh xzkae @ eqgYyk @ okMZ --------------------------------- Mkd?kj-------------------------------
xzke iapk;r@ uxj fuxe @ uxj ipak;r @ vf/klwfpr {ks= ifj”kn@uxj ipak;r @
dSUVksUeSaV cksMZ --------------------------------- rglhy ------------------------- ftyk --------------------------
fuosnu djrh@ djrk gwa fd esjs o esjs fdlh Hkh ifjokj ds lnL; ds uke ?kjsyw
,y0ih0th0 dquSD'ku ugha gSA


Hkonh;
LFkku
-------------------------------




vkosnd dk uke o irk
fnuakd -------------------------------

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