(Rgwb dig - 1)

webvg~‡j¨ weZi‡Yi Rb¨

Rb¥ wbeÜb Av‡e`bcÎ 1

bvg
w`b gvm ermi
Rb¥ ZvwiL msL¨vq bvix
wj½
(wLÖt) cyi“l
K_vq

Rb¥¯’vb2
†`k t evsjv‡`k

wcZvi bvg RvZxqZv gvZvi bvg RvZxqZv

†`k t evsjv‡`k/..................................

†`k t evsjv‡`k/..................................

Avwg ¯^Áv‡b †NvlYv Kwi‡ZwQ †h, Dc‡i ewY©Z hveZxq Z_¨ mwVK, wbeÜbvaxb e¨w³i Ab¨ †Kv_vI Rb¥ wbewÜZ nq bvB| Av‡e`‡bi ZvwiL (msL¨vq)
bvgt

¯^v¶i/ wUcmwn
m¤úK© t wcZv gvZv (wUK wPý `b)| Ab¨vb¨ (m¤úK© wjLyb) t .......................................................... w`b gvm ermi

R‡b¥i 5 eQ‡ii g‡a¨ Av‡e`‡bi †¶‡Î ïaygvÎ 1 bs Kjv‡g cÖZ¨qb cÖ‡qvRb nB‡e| R‡b¥i 5 eQi c‡i Av‡e`‡bi †¶‡Î wkÿv cÖwZôv‡bi eZ©gvb ev cÖv³b QvÎ/QvÎx
nB‡j 2bs Kjv‡g ïaygvÎ mswkøó wkÿv cÖwZôvb cªav‡bi cÖZ¨qb cÖ‡qvRb nB‡e| Ab¨vb¨ Av‡e`bKvix‡`i †ÿ‡Î eqm cÖgv‡Yi Rb¨ 2bs Kjv‡g GgweweGm Wv³vi Ges
Rb¥¯’vb/¯’vqx wVKvbv cÖgv‡Yi Rb¨ 3bs Kjv‡g BDwc m`m¨/KvDwÝj‡ii cÖZ¨qb cÖ‡qvRb nB‡e| Z‡e wbeÜK KZ…©K wbw`©óK…Z †Kvb GbwRIKg©x eqm I Rb¥¯’vb/¯’vqx
wVKvbv cÖgv‡Yi Rb¨ 3bs Kjv‡g cÖZ¨qb Kwi‡Z cvwi‡eb| GQvov BwcAvB KvW©/GmGmwm ev mggv‡bi mvwU©wd‡KU/cvm‡cvU©/nvmcvZv‡j Rb¥ msµvšÍ QvocÎ/Rb¥ ZvwiL
Ges Rb¥¯’vb m¤cwK©Z wbeÜK †hBiƒc cÖ‡qvRb g‡b Kwi‡eb †mBiƒc †Kvb `wj‡ji Abywjwc (†h †Kvb cÖ_g ev wØZxq †kÖYxi miKvix Kg©KZv© ev wk¶v cÖwZôv‡bi
Aa¨¶/cÖavb wk¶K KZ…©K mZ¨vwqZ) mshy³ _vwK‡j wb‡¤œi †Kvb Kjv‡g cÖZ¨qb cÖ‡qvRb nB‡e bv|
Z_¨ msMÖnKvixi3 cÖZ¨qb (¯^v¶i, ZvwiL GgweweGm Wv³vi ev mswkøó wkÿv cÖwZôvb cªav‡bi BDwc m`m¨/ KvDwÝji/ GbwRIKg©xi cÖZ¨qb
I bvgmn mxj) cÖZ¨qb (¯^v¶i, ZvwiL I bvgmn mxj) (¯^v¶i, ZvwiL I bvgmn mxj)
(1) (2) (3)

wbe܇Ki Aby‡gv`bt ¯^vÿi, ZvwiL I wbeÜb ewn‡Z wjwce×Kvixi ¯^v¶i,ZvwiL wbeÜb ewn bst
bvgmn mxj I bvgmn mxj wbe܆bi ZvwiLt ............./............../............................
e¨vcb Gi †kl Qq AsKt
e¨w³MZ cwiwPwZ bs (e¨cb)t

Rb¥ mb` cÖ`v‡bi m¤¢ve¨ ZvwiL ............./ ............./ ..................

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Av‡e`bKvixi Ask4 (Z_¨ msMÖnKvix/ Rb¥ Z_¨ dig MÖnYKvix wb‡Pi AskwU c~iY Kwiqv Av‡e`bKvix‡K †diZ w`‡eb)t
wbeÜbvaxb e¨w³i bvgt
Av‡e`bKvixi bvgt Rb¥ mb` cÖ`v‡bi m¤¢ve¨ ZvwiL ........./ ........../ ...................
Z_¨ msMÖnKvix/ Av‡e`b cÎ ZvwiLmn ¯^v¶it
MÖnYKvixi bvg I c`ex
1
GB digwU BDwbqb/ †cŠimfv/ wmwU K‡cv©‡ikb/ K¨v›Ub‡g›U †ev‡W© Rb¥ wbe܇bi Rb¨ cª‡hvR¨ hvnv Av‡e`bKvix ev wbeÜK Kwc Kwiqv e¨envi Kwi‡Z cvwi‡eb|
2
BDwbq‡bi †ÿ‡Î wVKvbvt (1) MÖvg (2) BDwbqb (3) Dc‡Rjv (4) †Rjv| Ab¨vb¨ †ÿ‡Î wVKvbvt (1) †nvwìs/evmv bs (2) mo‡Ki bvg ev bs (3) †gŠRv/gnjøv (4)
IqvW© bs (5) †cŠimfv wmwU K‡c©v‡ikb/K¨v›Ub‡g›U †evW©|
3
KvDwÝji, ¯^v¯’¨Kgx©, cwievi cwiKíbv Kgx©, GbwRI gvVKg©x, nvmcvZvj ev wK¬wbK KZ…©c¶, †Rjvmycvi, wk¶v cªwZôv‡bi Aa¨¶/ cªavvb wk¶K|
4
mb` MÖn‡Yi mgq Av‡e`bKvix Zvi As‡ki Aci c„ôvq ¯^v¶i Kwiqv mswk−ó KZ„©c‡¶i wbKU Rgv w`‡eb Ges Rb¥ mb` msMÖn Kwi‡eb|