-

et

ftR;rr ~

311<tl~<tldl

~d"1>illft

fuc;rr

"iJ!l"\f'g I ~

"'1141('1"11

qGqlf

fuc;rr ~ ~

fcnm

qG"1I'1,

(Cflc'lCfC'I tc/'I'ifclGT)

Ti

/"'tl(jl!f

x:flft 311CI~4 Cfj J:ll'lTUT cnr

15 ~<R,

311~G"1 QR t1<tldl

Juft

etI

~lf.'Iql'l)

311Cfjff+1Cfld 1 ~

9141q Rl

(~EfR)

2014

m-r ~

t)

'l1cfi/f.'1;gFck1 ~

qjt ~

"'1141&14 cf; Cfl141&14 Ti ID'{'f

\iff

6t

(15, "1'11'<'1'1 2014,

Ti ~

~ufi

Rt $II q"1

t11e11('<f)1'I qlt

tr?I. 3I'fffJ:r ~

etI 'l1cfi ~
(1)

f.mffuf

1f?I

\R[

Rt $I ~

f.n.!fiffi- ~

illcl<tl /~~

("<tl'~'fC"X ~('I~fcrGT)qlt

: (15 31<tCe.fI.( 2014, ~EfR)

Cfj4ill~.

lR <lllR

qlt

f<l;<l ~

"'If\J'4 cf;

cf; ~

(fj1f~,

(i), (ii), (iii) l{ ~ ~

(3fl'4":!ff qGqlf

qlt ~

"'llllllcl~'
1Rff /

311~G"1 ~
3I'fffJ:r ~

~~m-. \J1"h"l'IX

'i'lllm."1 'Q

etI

3111181C1 fcP"it

WIl

5.00 "if\if "CfCl'

Ti fffil

W" % 1

~d"1'11"1 ol!.1T 31Jdl~'

:~~

<lllR

ill cl <tl (311Cflff'1 Cfjd I ~

Cfj4ill~/

it e1fill <tl anhrr

3!TOcft <pan
\3 Cf1l 01

(<tlcl'l'C'(

ctlCfl&1

il"C'fR cpj

/'I'ifclGT) ~

em

'J?14~"1 &114\'1'Ii

<111
Cflff'1CfldI ~
~ ~
Cfl4ill~ /~
/ il1'1;'jGI'I /<ncX1f"1"/ 1ffiifi (~'fC"X
~ /

<tlcl ete'l ~c

~)~
Cfl4ill~ / 'I'<llq'l (<tlcl etC'!
te / 'I'ifclGT) >fCl'f

tN :-

tr?I ~

3llfurti ~
lfCtlflf

(i) ~

<tT 31fdl:!

-mfcr .,t'W"!
ft'rfu "CfCl'\3rol 01 m-r 311CI~4 Cfj 'g I
"\'fl14" \34xlCRlI'j)\'iI'l

illclifl

ci>

llQlf
"'IT.
<1>.

""11 ftl if) ~

31 <.'"1'1 \( I\J1 T<

(31I<tl~<tldl
~
llGT qlt 3I"ReJUT X tc'l
Q>T "'fIl'f

et

~d"1>ilIf) ifl4illfi/iflcl<tC'I
011. til '( fUI '11'1 ~fcl
<rolll

310fltoqrf

tTalfilTcp /dCfl'11<ti

~/'11RtGI}

cl

3Plo\ifTfir

3PlO\i1 \i1IRl

1
1

1
1
1

m.r

3j

~'1 1';1'1~'1

.--;;r~
-(

I
I

2
7

fu"G%$1

Gllfg

10

:fIT

11

lqlfc1"N

12

13

\il iiiC'l9>~

"1:11111C'l11

14

~3IT

15

'lSIo;gq I

16

17

rft1f<l

18

xl"lfl1

19

X1\'P I <i>

20

"trcrr

21

22

fuq-;fi

23

24

25

~ct>"P 1q;

26

I3vJ'1

1
2

(~'fC{

Iuffi

<i>T

3lC'1lxl\i1gx

ii1lcllt1lc

3T'!o\il"lftr

1x61'igx

'C9dx9>~

"1:11111C'l11

3T'!0 \il '1 \ill Rt

~
~
~

m-.r

1
1

1
1

1
1
2

fu"Gql'$l

Gllfg

1
2

'11'11(>1

39

"*

3loflro'flt

"*

1
1

i i Ii j i i

i5'

"ff ~d'1ofl,f) q>4i1I.tl/~/tfl<6lGI'{jqIW'l"1/1ffiift

te/tifc'lGI) lJ'f'f
lJGl qft 3TRlffUT xh::c~
3ljifllx
fttJlqlx

RF<tt1"l1 :"1:11111<tI

3
1

26

(ii) 3l1q>~q>d1 ~

4GQ'f

m.r

ifI.

1
1

5
3

3
2

9
6

3
10

G"fum

11

12

~og);ft

13

"TIT

14

' q 1f(;j <l"!

15

16

S)~iII16l1C;

17

~.

25

11

18

1
3

\iI GI<'1g'<

"'"l1<11<'1<1

17

3
1

1
2

1
3

1
2

6
1

60

19

~3lT

20

\'5l;Sql

21

CflCr\I

22

'1,<~$g,<

23

;ft1:rq

24

xr<R1'f

'<1\J1'1 <t>

CJWl "'"l 1<11wI

26

'<(1 <'11'i

27

mT

mTR

25

28

~
29

"'"l1<11<'1<1

1
1
3

fucRt

3
7
3
2

1
2

1
2

10
2

11

30

"'"l1<11<:'1<1

31

~1$'S1<'1

32

33

ffi1mc;rr - fu.

C1C!J'i 'I <i>

34

35

~
38

"'"l1<11<'l<1

Fcl~~11
~

37

\3~'i

~
36

"'"l1<11<'1<1

1
1
1

"'"l1<11<:'1<1

fi1u'5
m1'f

9
4
4
1

1
2

"'"l1<11<'1<1

1
2

1
1

107

45

43

2
1

28

5
2

11
18

39

295

4
q wf (iii)

31ICf>rt<tCf>dI f.Iftr ~ ~d"'1<il.ft

<5
~. Y'lll PI if>

;:w:r

<P.

lfGl

<P1f~/~
(~CfCi{ tc/~fc'lGr)
qft 3lRlffOT t1'R,< <5 311'<"11'<l\i1<.hl'< RFch1'l1 :-

m "<i>T

310fltOcrrt

~
"IlIRI

3l<1"J'<I\ilg'<

fU"Gql'$l

c:ffrm

5Xc:T

I!!l O;&qI

"'1'<ffj g g'<

"IlIRI

3T"l0\iI'1\ill Rl

3T"l0~
"IlIRI

"IlIRI

m>r

1
1

'XlllllC'lll

2
3

;ftlfiI

10

"lr<Pf

11

,<I"P I<t>

12

'<(1C'l!"1

13

fucRt

14

eI C/i'1'1 <t>

15

\3W1"'1

16

~
'Xl1'llclll
"IU;&c'I~q,<

17

4
1

'Xlllllclll

2
2

3
1

t9d~'J,~

"$I

rITe :-

<5

1JUI\l~~1 ~

~~

f.'lll"llj'<'1I'<

"C/iT3fR1ffUT '<'1'i,<'<1f111
~

3W.!qft ~

(2)

~f.'lC/i'i ~

3lRfem

(S)f1\Jl1"Ccl ~

34

10 >l1'd~1(1 "(fG ~
C/iA:tle4'"Cqlli\Jl) ~ I

:-

RHIC/i 01.01.2015 q;) ~'1(1'i 18 ~ qft 3lT<J ~

~
3lIq~1lC/i %. \3Cffi ~
lR
~ ~
3lT<J "'<fr1TIqft 1"fUf'ff ('1.">1".
~.
'<'11
'11'Xl >I~II'<'1'i fctlwT. !OJ ?IIclll. ~
cf; ~
CPo "'<ft 3-11/12/1/3,
~
fG. 03~.
2012 ~ ~
CPo "'<ft
3-11/2012/3/1T'P.
~
fG. 20~.
2012 cf; 31j'<1T'<) f.'lkjlj'<'1l,< mlft:1.

3l1tc:cn (~

crf)

40 ~

2.

~
3l1tc:cn (~II'<'1c6111/ f.'rTl1 / lfll'5(;l
l~II+;'lll <=R1211 cf; C/i.\'illfl ~
~
~)

45 ~

45 ~

~11'<'1Cj')'lll/
cf; C/i4i11f1 "d"m ~

45 ~

3.

~
3l1tc:cn (3lRfem crf(3110"\Jll"fu/ 3110\J1"1\J1II'd / 3l0f1'tocrfo)

4.

~
~
f.'rTl1 /lfll'5(;l

(3lRfem crf/ l~IIf1"lll ~

~)

-;

0:

-;

~1<

"I

-;

iZ

~ ~ ~. ~ Ir

!
~
I

W
~

~I

:::.

l~!~ I
h~l;,'"
~tr&~ ~

I~ f

It ~1!
@ g
.I.

~UI
IHf

~~<f\fJ1

1C

~1
~
i~
h

1Y

-~

-~

lO

ft
i

<D

-2.

--~

.~! ~

--S

'W

i 1

~~

?5

10

t ~

~.w i

10

--....s.

2-

!~

~..

---!e-..t::-

1&.-

t9

i i ,- ~ 1&
f ~ I !~
1h

1ii ~ '"

1~

t
i

1 f _ -Ii 1 :U~
E t .~ ~ ~"'''"t
~!
~
~
~1r5
i w I ~t

H
t
~'"
~

~ ~ -

,:~ ~ ';~, i ~~

;;;;

&t

~ 1,:;

""

1&

~
'"

ij; 1Y ~

.~

~..:!..

'Ii

iiI!"" i

~ g~
U:I_i~f"'~!,,~
"".~i;

J)j

""
~~

~"~

.~ is

t ~i ~
p
i
'Ii

1.~ :E ~

i ,~~

1& ~

<C

't ! ~
~
i~.
r .~~lO~ll"'H

r--:

~
,.!2.

hI!; i~
h h 1 ~ 1h h 1 ~ I n h ; ~~h

i i ,,1
Ll1W

1'f

6
(10)

wrrf

3fRfa'ffi

'l'fTtm;r

M~lIfl'1 ~,
1996 1;(Ci W1fiq)
~

(11)

(12)

(13)

cnW fcrmx

\i1l,q 'II I

"'1tT ~

-gg
~ ~

'1C<1 <R !>lG~f\'1

wen
/~

ftffi

filtll'i!l~
Gfil'Sd

31 ~<R,

ett ~

jMI<:'1""ll

<f; ~

m 3fi1.TClT~

tt ~

3R!~

"4?if <R

ett

3ifff'i

(~<t><ll'i!) Cfi'TfuR;rr '"'1111<:'11

<f;

2014

tt ~

fcn<rr

if)[

Glfil'SCfi >fCRUT ~

<f; ~

GlfIltcJ 3j'R:[~

C/JX~

<R ~

-gg "'i~ xt

3l1""l)f\J1\'1 lMt, "f11~

\fIWTT I ~

cnW

tt ~

Cfi'T CT ~

<R ~

~/'"'1111<:'11

Ti

Wl'T 6T 3fi1.TClT~ C;'I'lffl'i'i CIR

1;(Ci tim ~
>fCRUT W1fiq) ~

<f I

(etG

\I <l>1'l1)
'i!Rit~R
\i1'1'i!cl

***

if)[

'"'1111<:'11
xt r.t'i!IClI.\'1if

fcn<rr "l]<IT if ill f.1uf<:r / ~

\i1I'1CfiIf1 3lr.tQI4d:

01.08.

11<1 f.'ftm <f;

~ ~

ett ~

erg fuR;rr '"'11II<:'1I CfiIIf<:'1I ~ "i/?TIf ~

3j'R:[~

I
~

"'1tT

fll '1I'"'1

<f; q~tllq

m,

96/3f->T/1,

\ifffi1 WJTOT Lf?f

fi'l;<l11<1 3l1~G'11

~_

"i:I"\!ffi'f'Jf<l

Lf?f ~

m~
ett

fuR;rr

1;(Ci3ifff'i

f<I~ClI.\'13i1x f.'rffil

x~

12.03.1997

wrrf <f; me'! fcrmx ~ ill ~

<f; ~

07-26/

&NT ~

fiI$1f?<1 MCfiI~I'1 ~

W1fiq)

7-2/96/3f->T/1,

(14)

&NT ~

~e11'! ~

3f0fi'tOCTO) <f; 3j'R:[~

(3W"fT0, 3fjovro\ifffi11;(Ci

--

lBr "ij)f gl~q/ /

/ /~

qft ~

l1mm ~
311I <t>1lti<t>d
31

"fl

I ~

WJ1RT3IT TR ~
T.llcl<t> [i'.rql!f
~d -sfl.rt <t>4T.1lfl/W (~'ifCX tc/~)
'JRff
all ~ G.... tBJ

.l3tuft.
qft ~

fttcll

tq

m.
~
ftR;rr ~ ~
ftR;rr '"'<11111
C111
J"I"O'Im)

~.

qltlq1

~\jf

"<t>T

'fClR

"Q1j ~

1.

l::fGCl'f

ftrn -gg ~

em~.
~

2.

3l1~C;CfJ

em

3.

m/Sex (~~

4.

f\'lm I %1 em ~

5.

6.

~/cB<?;'I~ ~/UR

7.

<flIT

8.

'lR - .'>ft I

~/Male

'BfT/Female

~o

01 101 12015 q;) 3111

m cf; ~

9.

CfllT

m~

fI f.'ICfJ ~

10.

<flIT

em

3Wtq/OBC

i'f ~

~)

f.'Iql;ff1 ~ ? (~ <:IT "1tT

'If ~

~)

(if

em

i'f ~

l'fl1>

(~ <:IT "1tT

fc1CfJC1i'l ~ ?

3111 ~

'Cflf

3f\ilT/SCmiST

CfllT

(qfl1 ~

'If ~

<:IT "1tT
~ I

(if

~)

<IT "1tT i'f ~

~)

31ltI"R

1fflT I Permanent
(ftR;rr.
fCl'1 CfJI;s

~qif)l;Q

CfR '('jCfJdl ~)

f.mR~)

If>Tcl mIT

m 3lft'~
m~

11.

leg

i'f (J)

~'11CfJ -

~ if cIT ~

-gg tl ~

qc;c.jlf

(~2ff

CfR ~

m~

Address

~)

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

12.

Q?llill'<!

(fuwrr.

em

1fflT

I Correspondence Address

m ~ fCl'1CfJ1'S~)

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

13( ~).

"I'IOII~C1/m ~

13(ifi).

3ITtTR ~

(~

m. cIT) -

m (~ m cIT) -

'

'

.
.

__

14.

I~

w.

qr;f

'!ll~iq-

'If)T CTq

'!lftrno

I~

3RT

~ ~

d if) '11C/J I
~
~

~mfilrcpl
m:rr
ll"'lldJ

'Cfl5'1'

~I

15. l{<f 3PJ'I1<l :-

~.
<1>.
1.
2.

fqfl'fl ~
<;1'1 ff1'fl / <; fil;s C1 t

16.

'flIT ~
(<1ft

-g

3l\'.1CIT ~

-g

XN

3l\'.1CIT ~

51 m. fqq'<l ~) -

qq;xur
"iVlff'iP

"iV.

1'1 Cf)'<0l

E11'<1~'

"'lIllll t't II CfiT<wr

f.nm/~
~q;

R'lIit

/~

1.
2.

PI S11fi;tR:l d G'Rli ~ \ill / qlJTUT "ll?IT ~ ~ lJlnfitrd'

'fi t't. '1 fc);m \ifRT
3fRI~
&RT ~(>fT.f ~

t: -

(J) 3T~

~(>fT.f ~

mm~

WfTUT 11?1 (<1ft ~

cIT (X)

\JA

\i'flftr WfTUT l:R 3l\IIT / m

1WT

"
~
/3lft~
fqCf)e'1ill 31RT~
WfTUT 11?1 (<1ft C'fT1l
tT~ ti'I'jC1I31T ffiqr WfTUT 11?1

Pi q Itil

/ 31fqq ~

5
6

311~GCf) "CfiT1(Cf) ~

WfTUT 11?1 ~

YI'{lYIC

m'Cf)T

~)

'Cf)T

4>1clUllfi

31Tit'G"<P
<t trnrrm ~ <wr
Name & Signature of Candidate

/Place :--------------------------~'1.ICf)/Date : ---------------------------

II
Elltiloll

&RT ~)

61)

(<1ft

Tf ~

it ~

/WfTUT 11?1)
~

WfTUT 11?1 (x-rafl1 ~

msm

CfiTPI'tII'1 t't'lIlf

(~

m)

311~ G'1 <t ~

G'Rli ~ \Jl/ qlJTUT l:f?r <t

-qta:rr ~ 3tCfi ~

m "CfiT'@'

Ell til011

'fRill/~

'(

1/
fop

-,rot

~lffT

~fmf ~

R1~lq'1 q;)- ~
~
~
if "'<Pm fulIT t I \14'<lifd 'fPl'Rl \Jl1'1<t>I{)~
w;r if fcl:tqltl <t 31"j)t1I'<~ if ~l{uf t I mG ffi 311~G'1 R1~lq'1 ~ wff <t
3T"j)flq f.tt::rfftG wm 1{ ~
~T.RlT t 3T~
ftfRft 'Sfi ~
tR 3T1~G'1 1{ ~
'Sfi \Jl1'1<t>1~~
~/3T~
3Tl{uf tmf umft t 3T~
~ &RT ~
\Jl1'1<t>I{)
faql:{ umft t cIT ~
R1fl4i q;pf<mft ~ \Jl1<t>'<ffi 311~G'1 f<ptft 'Sfi q<l>1J tR
PI,<'Rl ~.
ffi lJChT. '<flR" ~ ~
PI,<'Rl ~ \ill t1<t>dl t 3T~
~
lfG
~ gcllli \ill t1<t>dl t I
~

/ Place :---------------------------

.~ '1'1<t>/ Da te : ---------------------------

311~G<t>~ g'RlIl:1'< ~ "fT1J

N me & Signature of Candidate