s]j\dpsS

kmaqlykpcms]j At]m t^mdw Ign 6amk

n\pn
FSp ]mkvt]m
kmaqlykpcm s]js t]cv : IjI sXmgnemfn s]j v Afhnep
t^mtm ChnsS
HnWw
For Office use only
s]j\ \ : s]j\ tImUv :
At]m \ :

C\w
1. KpWt`mmhns/ s]j\dpsS t]cv
(C\ojy t]cn\v tijw tcJsSpWw)
i. aebmfn :
ii. Cwojn :
Znhkw amkw hjw
2. i. P\\ XobXn/ ({InkvXphjw) :

ii. hbv : hjw

3. ]qamb tahnemkw (DZmlcWw
t\mpI)
i. hov t]cv :

ii. sInS\ hjw hmUv \ hov \

1995
2000
2005
iii. dknUvkv Atkmkntbj\nep
hov \ :
iv. dknUvkv Atkmkntbjs t]cv :

v. c/o tahnemkw :

vi. hoSns m\w kqNnnpXn\v km

[mcW D]tbmKn mdp {][m\ `ua
kqNIw (DZm: km m]\w, Bcm
[\mebw, ivaim\w, _mv, kzImcy m]
\w {Smkvt^ma FnhbntesXnepw.)
vii. hoSv nXnsNp tdmUns/sXcphns
/IhebpsS/{]mtZinI ens t]cv :
viii. {][m\ etcv (hoSv nXnsNp
ehpw kao]{]tZifpw DsSp
`mKn\p s]mXphmb t]cv) :
ix. tImtdj\n s]j\dpsS hoSv
nXn sNp ]pXnb CevIvSd
hmUns t]cpw \dpw (2005 se) :
t]mm^okns t]cv ]ntImUvv
x. t]mm^okns t]cpw ]ntImUpw

4. ]pcpj/kv{Xo :
5. AhiXbpsS kz`mhw :
6. hn`mKw : s]mXp hn`mKw ]nIPmXn ]nIhKw
7. tIcfn Xmaknambnv F{X hjambn :

1
8. KpWt`mmhns/ s]j\dpsS t]cv Dsnp tdj ImUns \ * :
9. _n.]n.F ImUv \ ** :
10. CeIvSd Xncndnb ImUv \ *** :
Ipdnv :-
*. tdjImUns BZys t]Pnsbpw KpWt`mmhns/ s]j\dpsS hniZmwi
tcJsSpnb t]Pnsbpw t^mtmtImn CXnt\msSmw lmPcmWw.
**. e`yamsWn (Zmcn{ZytcJbv Xmsgbph am{Xw).
***. CeIvSd ImUns CcphifpsSbpw t^mtmtImn CXnt\msSmw lmPcmWw.

11. \nehnep hmUv IuknedpsS t]cv:

BsI sXmgn ]cnNbw (hjn)

ap kmaqlykpcm s]j\pI kzoIcn C :
pptm?. (Dsn GsXv hyampI) : Dv :

hnhmlnX\mtWm? AsX : A :
`mcy/`mhv Pohnncnptm? Dv : C :
hniZamb hcpam\ kn^nv lmPcmnbn Dv : C :
ptm?
IjIsXmgmemfn ta\n[n cPnkv{Sj
\cpw hjhpw
{]mb]qnbmb BafpsS Fw
{]mb]qnbmb AhnhmlnXcmb s]afp
sS Fw
aq aIs P\\ XobXn / ({InkvXphjw) : Znhkw amkw hjw

BsI hmjnI hcpam\w :

`qhpSabpsS hnhc
{Ia t]cv tahnemkw F{X hjw
\ IjI sXmgnemfn
Bbncpp

Phone No. / Contact No.

ew :
XobXn : KpWt`mmhns Hv