065-2248165

tpz;zg;g ,y.
(tpthfuj;Jg; ngw;w/ fztdhy; iftplg;gl;l) ftdpg;ghuw;w
ngz;fs; tpguj;jpul;L
1. tpz;zg;gjhupapd; KOg; ngau; : …………….……………………………………………………
2. Kftup : ……………………………………………………………………………………………...
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3. njhiyNgrp ,y. : …………………………………………….
4. Njrpa milahs ml;il ,y. : ………………………….. taJ: ………….
5. fztdpd; KOg; ngau; : ……………………………....................………………………………..
a. tpthfuj;Jg; ngw;w/ iftplg;gl;l jpfjp : ………………….
b. tpthfuj;Jg; ngw;wikf;fhd/ iftplg;gl;likf;fhd fhuzk; :
……………………………………………………………………………………………………...
c. fztd; nra;J te;j njhopy; : ……………………………………….…………………….....
d. tpz;zg;gjhupapd; jw;Nghija njhopy; : ………….………………………………………….
6. jw;Nghija FLk;g epiy> kw;Wk; Njitfs; : …………………………………………………..
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7. NtW VjhtJ epWtdj;jpd; %yk; cjtp fpilf;fpd;wjh? Mk;: ,y;iy:
Mk; vdpd;> epWtdj;jpd; ngau; : ………………………………………………..............................
8. FLk;g mq;fj;jtu; tpguk;. (gps;isfs; njhlu;ghf)
njh. ghy; cwT fy;tpj;
,y. FLk;g mq;fj;jtu; ngau; (Mz;/ngz;) Kiw
gpwe;j jpfjp
juk;
njhopy; tUkhdk;

1.
2.
3.
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7.
8.
9.
10.

Njitg;gLk; Mtzq;fs;:
1. tpthfuj;J mj;jhl;rpg; gj;jpuk;.
2. rhu;e;jpUf;Fk; gs;spthay; my;yJ epWtdk; xd;wpd; mj;jhl;rpg; gj;jpuk;.
3. fztdhy; iftplg;gl;likf;fhd Mjhuk;.
kWgf;fk; ghu;f;f 
 9. cWjpAiu

a. tpz;zg;gjhup:
………………………………… Mfpa vd;dhy; toq;fg;gl;l Nkw;gb jfty;fs; ahTk;
cz;iknad cWjpg;gLj;JfpNwd;. mj;Jld; ,t;tpz;zg;gg;gbtk; vd;dhy; khj;jpuNk
xg;gilf;fg;gLfpwJ vd;Wk;> NtW vdJ FLk;g cWg;gpdu;fshy; toq;fg;gltpy;iy vdTk;
cWg;gLj;JfpNwd;.

jpfjp: …………………. …………………………..

ifnahg;gk;

b. gs;spthay; jiytu;:
………………………………… ngaUila tpz;zg;gjhup vkJ epu;thfj;jpd; fPo; cs;s
………………………………………. gs;spthay; k`y;yhtpy; trpj;J tUfpd;whu; vd;Wk;>
,tu; (tpthfuj;Jg; ngw;wtu; / fztdhy; iftplg;gl;ltu;) vd;Wk; cWjpg;gLj;JfpNwd;.

jpfjp: ……………… ……………………………

gs;spthay; Kj;jpiu ifnahg;gk;

c. fpuhk Nritahsu;:
………………………………… ngaUila tpz;zg;gjhup> tpthfuj;Jg; (ngw;wtu;/ fztdhy;
iftplg;gl;ltu;) vd;Wk;> vdJ epu;thfj;jpw;Fl;gl;l ………………………………… vDk;
fpuhk Nritahsu; gpuptpy; trpj;J tUfpd;whu; vdTk;> ,tu; rKu;j;jp Kj;jpiu (ngWgtu;/
ngWgtu; ,y;iy) vdTk; cWjpg;gLj;JfpNwd;.

jpfjp: ……………… ……………………………

gjtp Kj;jpiu ifnahg;gk;

mYtyf cgNahfj;jpw;F
tpz;zg;g ,y.

Fwpg;G: ……………………………………………………………………………………………………..
………………………………………………………………………………………………………………
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,t; tpz;zg;gk;> Vw;Wf;nfhs;sg;gl;lJ> Vw;Wf;nfhs;sg;gltpy;iy.

jpfjp : ………………. ……………………………

xUq;fpizg;ghsu;