evsjv`k wbevPb Kwgkb

wbeb dig
Rb ermi

Rjv

(dig-2)

Avi.Gg.I.

DcRjv/_vbv

wgK bs:

BDt/IqvW/Kvt evt

ewMZ b^i

1| ewMZ cwiwPwZ
b^i (PIN) :
Rjv

fvUvi GjvKv

fvUvii wgK b^i

2| fvUvi b^i
(Dcii Ask Awdm KZK ciY Kiv ne)

3| bvg

4| Name

5| wcZvi bvg

6| gvZvi bvg

10| Qwe

7| ^vgx/xi bvg :
8| wj ( w`b)

: cyil

gwnjv

9| eevwnK Aev (

w`b) : weevwnZ/ AweevwnZ/ ZvjvK cv/ weaev/ wecZxK

11| ckv ( w`b): miKvix PvKzix/emiKvix PvKzix/Wvvi/Bwwbqvi/wkK/AvBbRxex/eemv/ZgRyi/kwgK/KlK/Qv/Mwnbx/eKvi/Abvb................

12| Amvg_Zv/cwZexi cKwZ (hw` _vK) ( w`b) : `w cwZex/kvixwiK cwZex/keY cwZex/evK cwZex/Abvb..........................
w`b

gvm

ermi
14| eqm

13| Rb ZvwiL :

ermi 15| Rb vb :.................

(Rjv)

16| eZgvb wVKvbv :

wefvM : .............................

Rjv :.................................

DcRjv/_vbv:......................................

wmwU Kcvikb/cimfv............................................BDwbqb/ci IqvW/Kvt evt....................................

IqvW b^i (BDwbqb cwil`i Rb):.............................gRv/gnjQv .........................................................
Mvg/ivvi bvg I bs : ......................................................................................................................
evmv/nvws bs :...............................................................................................................................
WvKNi : .............................................. cv KvW : ..........................................
Avi. Gg. I. ( w`b) : cjQx / cimfv / kni / Ab GjvKv / wmwU Kcvikb
17| vqx wVKvbv :

wefvM : .............................

Rjv :.................................

DcRjv/_vbv:......................................

wmwU Kcvikb/cimfv............................................BDwbqb/ci IqvW/Kvt evt....................................

IqvW b^i (BDwbqb cwil`i Rb):.............................gRv/gnjQv .........................................................
Mvg/ivvi bvg I bs : ......................................................................................................................
evmv/nvws bs :...............................................................................................................................
WvKNi : .............................................. cv KvW : ..........................................
Avi. Gg. I. ( w`b) : cjQx / cimfv / kni / Ab GjvKv / wmwU Kcvikb
18| fvUvi GjvKvi bvg:

b^i t

cvw iwk`

wgK bs:

bvg : ............................................................................................................................................................................

Qwe Zvjvi K` :................................... ZvwiL :............................. mgq: ............................

PIN

b^i

Z_ msMnKvixi bvg I ^vi : ....................................................

19| wkvMZ hvMZv ( w`b) : wbii/5g/GmGmwm/`vwLj/GBPGmwm/Avwjg/wWcQvgv/vZK/dvwRj/mvb/gvvm/Kvwgj/Abvb..............

20| `kgvb mbv KiY wP :............................................................................................................................................

21| ii Mc (hw` Rvbv _vK) ( w`b) : A+ / A- / B+ / B- / AB+ / AB- / O+ / O22| wU AvB Gb (TIN) (hw` _vK):.....................................................................................................................................
23| WvBwfs jvBm b^i (hw` _vK): ...................................................................................................................................
24| cvmcvU b^i (hw` _vK) :...........................................................................................................................................
25| IRIS/DNA :.........................................................................................................................................................................

26| Uwjdvb (hw` _vK):.............................................................. gvevBj (hw` _vK) :......................................................

27| RvZxqZv.................................................................................................................................................................
28| Z_`vZvi Avsji Qvc :
evg nvZ
A dig ewYZ Z_ Avgvi vb I wekvm gZ mY mZ|

Z_`vZvi ^vi/wUcmB:
ZRbx

evswj

Z_`vbKvix KZK cwiewkZ Z_vejx mwVK ewjqv cZqb Kwijvg :

mbvKvixi bvg I ^vi

Z_ msMnKvixi bvg : ..............................................................

^vi I PIN

mycvifvBRvii bvg : ............................................................

^vi I PIN

cZqb KwiZwQ h, DwjQwLZ weeiYmgni mZZv hvPvB KwiqvwQ:

hvPvBKvixi bvg : ..................................................................
^vi I PIN

GwU AcviUii bvg: .................................................................

^vi I PIN

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

mnKvix iwRkb Awdmvi: ..................................................

29| gZz ZvwiL (nvjbvMv`i chvR)

w`b

gvm

ermi

Avwg RvZxq cwiPqc eywSqv cvBjvg|

MnYKvixi ^vi : ...............................................