¹ãì¥ãñ ØãðÖãä¶ã½ããÃ¥ã Ìã àãñ¨ã ãäÌã‡ãŠãÔã ½ãâ¡ß

(½Öã¡ãÞãã Ü㛇ãŠ)
PUNE HOUSING AND
AREA DEVELOPMENT BOARD
(A UNIT OF MHADA)
ØãðÖãä¶ã½ããå㠼ãÌã¶ã, ‚ããØãÀ‡ãŠÀ ¶ãØãÀ, ¹ãì¥ãñ - 411001
ªìÀ£Ìã¶ããè :26128856,26126381,26128868,261280802, ¹ãùŠ‡ã‹Ôã : 26123614

(20% Housing Scheme), ÔãÌãÃÔãã£ããÀ¥ã ¹ãÆÌãØããÃÔããŸãè (General Public) ¹ãã¨ã¦ãñÔããŸãè ÔããªÀ

‡ãŠÀãÌã¾ããÞããè ‡ãŠãØ㪹ã¨ãñ Ìã ¹ãƽãã¥ã¹ã¨ããÞããè ¾ããªãè.

1. ‚ã•ãêãÀãÞãñ ÔÌããè‡ãðŠ¦ããè ¹ã¨ã (¶ã½ãì¶ãã Ôã) Ìã ¹ãƽãããä¥ã¦ã ¹ãŠãñ›ãñ (¶ã½ãì¶ãã ¹ãŠ)

2. àããä¦ã¹ãî¦ããêºãâ£ã ¹ã¨ã (ãäÌããä֦㠶ã½ãì¶ãã (àã)) Á. 500/- Þ¾ãã Ô›ù½¹ã ¹ãñ¹ãÀÌãÀ
3. ½ãÖãÀãÓ›Èã¦ããèÊã ÀãäÖÌããÔã / ÌããÔ¦ã̾ããÞãã ªãŒãÊãã
 Ôãàã½ã ¹ãÆããä£ã‡ãŠã-¾ãã¶ãñ ãäªÊãñÊãñ ¡ãñãä½ãÔããƒÃÊã Ôããä›Ããä¹ãŠ‡ãñŠ›, ½ãÖãÀãÓ›Èã¦ã ãä‡ãŠ½ãã¶ã 15 ÌãÓãó ÌããÔ¦ã̾ããÞãñ
ÀãäÖÌããÔã ¹ãƽãã¥ã¹ã¨ã.
4. „¦¹ã¸ããÞãã ªãŒãÊãã ãäª. 01/04/2017 ¦ãñ 31/03/2018 ¾ãã ‡ãŠãÊããÌã£ããèÞãñ
4.1 ‚ã•ãêãÀ ¶ããñ‡ãŠÀãè ‡ãŠÀãè¦ã ‚ãÔãʾããÔã :-
 Ìãñ¦ã¶ã ¹ãƽãã¥ã¹ã¨ã ¶ã½ãì¶ãã "†" ãä‡ãâŠÌãã ‚ãã¾ã‡ãŠÀ ãäÌãÌãÀ¥ã ¹ã¨ã
 ‚ã•ãêãÀãÞ¾ãã ¹ã¦ããè /¹ã¦¶ããè ¶ããñ‡ãŠÀãè ‡ãŠÀãè¦ã ‚ãÔãʾããÔã ¦¾ããâÞãñ ¶ã½ãì¶ãã "†" ½ã£¾ãñ Ìãñ¦ã¶ã ¹ãƽãã¥ã¹ã¨ã
4.2 ‚ã•ãêãÀ ¶ããñ‡ãŠÀãè ‡ãŠÀãè¦ã ¶ãÔãʾããÔã :-
 ‚ã•ãêãÀãÞ¾ãã ¹ã¦ããè /¹ã¦¶ããèÞãñ ¶ã½ãì¶ãã "‡ãŠ" ¹ãÆãä¦ã—ãã¹ã¨ã
4.3 ÔÌã¾ãâÀãñ•ãØããÀ Ìã ‚ãã¾ã‡ãŠÀ ªã¦ãã ‚ãÔãʾããÔã :-
 ‚ã•ãêãÀãÞãñ ‚ãã¾ã‡ãŠÀ ãäÌãÌãÀ¥ã ¹ã¨ã
4.4 ‚ã•ãêãÀ Íãñ¦ã‡ãŠÀãè ‚ãÔãʾããÔã :-
 Ôãââºãâãä£ã¦ã ¦ãÖãäÔãÊãªãÀ ¾ããâ¶ããè ãäªÊãñÊãã Ôã¶ã 2017-18 ¾ãã ÌãÓããæããèÊã ‚ã•ãêãÀãÞ¾ãã „¦¹ã¸ããÞãã ªãŒãÊãã
ãå‡ãŠÌãã ‚ãã¾ã‡ãŠÀ ãäÌãÌãÀ¥ã ¹ã¨ã [‚ãÔãʾããÔã]
 ‚ã•ãêãÀãÞ¾ãã ¹ã¦ããè/ ¹ã¦¶ããèÞãñ ¶ããñ‡ãŠÀãè ‡ãŠÀãè¦ã ‚ãÔãʾããÔã ¦¾ããÞãñ ¶ã½ãì¶ãã "†" ½ã£¾ãñ Ìãñ¦ã¶ã ¹ãƽãã¥ã¹ã¨ã
 ‚ã•ãêãÀãÞ¾ãã ¹ã¦ããè /¹ã¦¶ããèÞãñ ‚ãã¾ã‡ãŠÀ ãäÌãÌãÀ¥ã ¹ã¨ã [‚ãÔãʾããÔã]
 ‚ã•ãêãÀãÞ¾ãã ¹ã¦ããè-¹ã¦¶ããèÞãñ ¶ã½ãì¶ã㠇㊠½ã£¾ãñ ¹ãÆãä¦ã—ãã¹ã¨ã.
5. ‚ãã¹ã¥ã •¾ãã Ô©ãããä¶ã‡ãŠ ÔÌãÀ㕾ã ÔãâÔ©ãñÞ¾ãã Öªªãè¦ããèÊã ¾ããñ•ã¶ãñ¦ããèÊã ¾ãÍãÔÌããè ‚ã•ãêãÀ ¢ããÊãã ‚ããÖã¦ã ¦¾ãã Ô©ãããä¶ã‡ãŠ
ÔÌãÀ㕾ã ÔãâÔ©ãñÞ¾ãã Öªªãè¦ã Ôãªãä¶ã‡ãŠã /¼ãìŒãâ¡ Ìã ÔãÖ‡ãŠãÀãè ØãðÖãä¶ã½ããÃ¥ã ÔãâÔ©ãñÞãñ Ôã¼ããÔ㪦Ìã ¶ãÔãʾããÞãñ ¹ãÆãä¦ã—ãã¹ã¨ã.

 DD / NEFT / RTGS :- 1. DD:- MHADA PHADB LOTTERY, Payable at PUNE.

2. NEFT /RTGS :- A/c No. 0263201001846,
IFSC :- CNRB0000263, Bank:- Canara Bank, Koregaon Park,
Pune

------------***********************--------------
 अर्जदाराने कागदऩत्र/प्रमाणऩत्र/दाखऱे/ऩुराळे या चेकलऱस्टसह र्ोडून सादर
कराळेत

महत्ळाची सच
ू ना : अर्जदाराने त्याऱा ऱागू होणा या ननकषाप्रमाणे सादर कराळयाची
घोषणाऩत्रे साध्या कागदाळर करता येतीऱ. त्यासाठी न्यानयक
कागदाची (Stamp Paper) आळश्यकता नाही.

अर्जदाराचे नाांळ:

योर्नेचे ठठकाण

योर्ना सांकेत क्र. प्रळगज (category)

प्राधान्य क्र. अर्ज क्रमाांक :

गाला क्र.

(1) अर्जदाराने त्याऱा ऱागू होणा-या ननकषाप्रमाणे कागदपत्र/दाखऱे/प्रमाणपत्र र्ोडऱे

असल्याची खात्री कराळी, मर्कूर समर्ून घ्याळा ळ त्या नंतरच स्ळाऺरी कराळी.
कोणतीही माहहती खोटी आढलल्यास ळाटप रद्द करण्यात येयीऱ याची नोंद
घ्याळी.

(2) कागदपत्रे / प्रमाणपत्रे स्स्ळकारणा-या अधिका-याने मल

ू प्रतीसह प्रमाणणत प्रती
तपासन
ू स्ळाऺरी कराळी.

(3) पढ
ु ीऱ तक्तत्यातीऱ अनक्र
ु माांक 1 ते 9 मध्ये नमद
ू केऱेऱी कागदपत्रे सळज
अर्जदारांना ऱागू आहे त (सळजसामान्य गट आणण सळज आरक्षऺत गट/प्रळगज)
 नमन
ु ा `स`

ãäÔÌã‡ãðŠ¦ããè ¹ã¨ã

¶ããÌã :-
¾ããñ•ã¶ãã Ôãâ‡ãñŠ¦ã ‰ãŠ½ããâ‡ãŠ :-
‚ããÀàã¥ã ¹ãÆÌãØãà :-
¹ãÆã£ã㶾㠉㊠:-

¹ãÆãä¦ã,
½ãã.½ã쌾㠂ããä£ã‡ãŠãÀãè
¹ãì¥ãñ ØãðÖãä¶ã½ããÃ¥ã Ìã àãñ¨ããäÌã‡ãŠãÔã ½ãâ¡ß,
‚ããØãÀ‡ãŠÀ ¶ãØãÀ, ¹ãì¥ãñ - 411001
½ãÖãñª¾ã,
ã䪶ããâ‡ãŠ ________________ Àãñ•ããèÞ¾ãã ‚ãã¹ãʾãã ¹ã¨ããÔã ‚ã¶ãìÔãÁ¶ã ½ããè ‚ãã¹ã¥ããâÔã ‡ãŠßÌãî ƒãäÞœ¦ããñ ‡ãŠãè,
½ãÊãã Øããß¿ããÞ¾ãã Ôã⪼ããæã ãäªÊãñÊãñ ¹ãÆ©ã½ã ÔãìÞã¶ãã¹ã¨ã Ìã ¦¾ãã ¹ã¨ããÔããñºã¦ã ªñ¥¾ãã¦ã ‚ããÊãñʾãã ‡ãŠãØ㪹ã¨ãã¦ããèÊã (•ããñ¡¥¾ãã¦ã
‚ããÊãñʾãã) ‚ã›ãè Ìã Íã¦ããê ½ãÊãã ½ã㶾㠂ããÖñ¦ã.

½ããè ÜããñãäÓã¦ã ‡ãŠÀ¦ããñ /‡ãŠÀ¦ãñ ‡ãŠãè, Öãè ãäÔÌã‡ãðŠ¦ããè ¹ãì¥ãùã¥ãñ , ãäÌã¶ãã ‚ã›ãè Ìã Íã¦ããê ½ã㶾㠂ããÖñ Ìã ½ãã¢ããè ¦¾ããºããºã¦ã
‡ãŠãñ¥ã¦ããèÖãè ¦ã‰ãŠãÀ ¶ããÖãè.

ã䟇ãŠã¥ã :-
ã䪶ããâ‡ãŠ :-

‚ãã¹ãÊãã ãäÌãÍÌããÔãì,

(‚ã•ãêãÀãÞãñ ¶ããâÌã Ìã ÔÌããàãÀãè)

 नमुना `प`

‚ã•ãêãÀãÞ¾ãã ¹ãŠãñ›ãñÞãñ ‚ããä¼ã¹ãƽãããä¥ã‡ãŠÀ¥ã

(Verification of Applicant's Photo)

¹ãƽãããä¥ã¦ã ‡ãŠÀ¥¾ãã¦ã ¾ãñ¦ã ‚ããÖñ ‡ãŠãè, ¾ãã ¹ã¨ããÌãÀ ãäÞ㛇ãŠÌãÊãñÊãã ¹ãŠãñ›ãñ Öã Ñããè/Ñããè½ã¦ããè/ ‡ã슽ããÀãè ___________
___________________ ¾ããâÞãã ‚ããÖñ.‚ãã•ã ãäª._____________ Àãñ•ããè ÔãªÀ ¹ãŠãñ›ãñ ½ããè ‚ããä¼ã¹ãƽãããä¥ã¦ã
‡ãñŠÊãã ‚ããÖñ.

ÔãâØã¥ã‡ãŠãè¾ã
¹ãÆ¥ããËãè¦ãî¶ã
¹ãÆ㹦㠹ãŠãñ›ãñ

¹ãŠãñ›ãñ ¹ãƽãããä¥ã¦ã ‡ãñŠÊãñʾãã ‚ããä£ã‡ãŠã-¾ããÞããè

ÔÌããàãÀãè Ìã ãäÍã‡ã‹‡ãŠã

1. _______________________________
2. _______________________________

¾ãã ‡ãŠãØ㪹ã¨ããÞ¾ãã ‚ãã£ããÀñ ¹ãŠãñ›ãñ ‚ããä¼ã¹ãƽãããä¥ã¦ã ‡ãñŠÊãñ.

¹ãŠãñ›ãñ ¹ãƽãããä¥ã¦ã ‡ãŠÀ¥ãã-¾ãã ‚ããä£ã‡ãŠã-¾ããÞãñ Ôãâ¹ãî¥ãà ¶ããÌã ___________________________

Ôãâºãâãä£ã¦ã ‚ããä£ã‡ãŠã-¾ããÞãã Öìÿã ___________________________
Ôãâºãâãä£ã¦ã ‚ããä£ã‡ãŠã-¾ããÞãã ¹ãì¥ãà ¹ã¦¦ãã ___________________________

ã䛹ã :
1. ¹ãŠãñ›ãñÔããŸãè ŸñÌãÊãñʾãã •ããØãñ½ã£¾ãñ ¹ãŠãñ›ãñ ãäÞ㛇ãŠÌ㥾ãã¦ã ¾ããÌãã.
2. ¹ãŠãñ›ãñ ¹ãƽãããä¥ã¦ã ‡ãñŠÊãñʾãã ‚ããä£ã‡ãŠã-¾ãã¶ãñ ¦¾ããâÞããè ÔÌããàãÀãè ¹ãñ¹ãÀ Ìã ¹ãŠãñ›ãñÌãÀ ¾ãñƒÃÊã ‚ãÍããè ‡ãŠÀãÌããè.
3. Ôãâºãâãä£ã¦ã ‚ããä£ã‡ãŠã-¾ãã¶ãñ ¹ãŠãñ›ãñŒããÊããè ¦¾ããâÞãñ Ôãâ¹ãî¥ãà ¶ããÌã Ìã Öìÿã Ìã ¹ãì¥ãà ¹ã¦¦ãã ãäÊãÖãÌãã.
4. Ôãâºãâãä£ã¦ã ‚ããä£ã‡ãŠã-¾ãã¶ãñ ¹ãŠãñ›ãñ Ìã ºãã•ãîÊãã ¦¾ããÞãã Öìÿã Ìã ¹ãìãà ¹ã¦¦ãã ªÍãÃãäÌã¥ããÀã ãäÍã‡ã‹‡ãŠã ½ããÀãÌãã.
5. ‚ã•ãêãÀãÊãã ¹ãŠãñ›ãñ ‚ã•ãêãÀ •¾ãã ÍããÔã‡ãŠãè¾ã /ãä¶ã½ãÍããÔã‡ãŠãè¾ã ÔãâÔ©ãñ½ã£¾ãñ ¶ããñ‡ãŠÀãè ‡ãŠÀãè¦ã ‚ããÖñ ‚ãÍãã ÔãâÔ©ãñÞ¾ãã
½ããÊã‡ãŠã¶ãñ ¹ãƽãããä¥ã¦ã ‡ãŠÀãÌãã. •ãÀ ‚ã•ãêãÀ ‚ãÍãã ÔãâÔ©ãñ½ã£¾ãñ ¶ããñ‡ãŠÀãè ‡ãŠÀãè¦ã ¶ãÔãʾããÔã ‚ãÍãã ‚ã•ãêãÀãâ¶ããè
ŒããÊããèÊã ̾ã‡ã‹¦ããè‡ãŠ¡î¶ã ¹ãŠãñ›ãñ ¹ãƽãããä¥ã¦ã ‡ãŠÀãÌãã.
‚ã)¶ãØãÀÔãñÌã‡ãŠ
ºã) Àã•ã¹ããä¨ã¦ã ‚ããä£ã‡ãŠãÀãè
‡ãŠ) ÀãÓ›Èãè¾ã‡ãðŠ¦ã ºãú‡ãñŠÞãñ ÍããŒãã ̾ãÌãÔ©ãã¹ã‡ãŠ
 ¶ã½ãì¶ãã ''àã''
àããä¦ã¹ãî¦ããê ºãâ£ã

ÔãâØã¥ã‡ãŠãè¾ã
¹ãÆ¥ããËãè¦ãî¶ã ¹ãÆ㹦ã
¹ãŠãñ›ãñ

àããä¦ã¹ãî¦ããê ºãâ£ããÞãã Öã ‡ãŠÀãÀ¶ãã½ãã ã䪶ããâ‡ãŠ ..................... ¾ãã ãäªÌãÎããè ........Ìã¾ã .............. ÌãÓãó
¼ããÀ¦ããè¾ã ãä¶ãÌããÔããè ÀãÖ¥ããÀ ...................................................................... (¾ãã¶ãâ¦ãÀ "„‡ã‹¦ã
½ãâ¡ß" ½Ö¥ãî¶ã Ôãâºããñ£ãËñ •ãã¦ãñ) Þ¾ãã ¶ããÌãñ ¦ã¾ããÀ ‡ãŠÂ¶ã ‡ãŠã¾ããÃãä¶Ìã¦ã ‡ãŠÀ¥¾ãã¦ã ‚ããËñËã ‚ããÖñ.

½ããè Ö½ããè ªñ¦ããñ ‡ãŠãè, ½ããè ‚ã•ãà ‰ãŠ. ................. ‚ã¶Ìã¾ãñ ½Öã¡ã ´ãÀñ ¹ãÆãäÔã® ‡ãñŠËñʾãã •ãããäÖÀã¦ããè½ã£ããèË ¾ããñ•ã¶ãñ
‚ãâ¦ãØãæã Ôãâ‡ãñŠ¦ã ‰ãŠ. ............... ÔããŸãè ‚ã•ãà ‡ãñŠËñËã ‚ããÖñ.

½ããè Ö½ããè ªñ¦ããñ ‡ãŠãè, ½ããè ‚ã•ãêãÀãÞ¾ãã ¹ãã¨ã¦ãñÔããŸãè ‚ããÌãξã‡ãŠ ‚ãÔãËñËñ ªÔ¦ããÌãñ•ã •ãÔãñ ‡ãŠãè, Ìã¾ããÞãã ¹ãìÀãÌãã,
ÀãäÖÌããÔããè ¹ãìÀãÌãã, ÌãããäÓãÇ㊠„¦¹ã¸ããÞãã ªãŒãËã, ‚ã•ãêãÀ Ìã ¦¾ããâÞãñ ¹ã¦ããè/ ¹ã¦¶ããè ¾ããâÞ¾ãã ¶ããÌããâÌãÀ ¾ããñ•ã¶ãã Öÿãè¦ã ÜãÀ
¶ãÔãʾããºããºã¦ã ¶ãÔãʾããºããºã¦ãÞãñ ¹ãƹã¨ã, ÀñÎã¶ã ‡ãŠã¡Ã, •ãã¦ããèÞãñ ¹ãƽãã¥ã¹ã¨ã, ¦ãÔãñÞã ÔããªÀ ‡ãñŠËñËãè ƒ¦ãÀ ‡ãŠãØ㪹ã¨ãñ Öãè Ô㦾ã
Ìã ºãÀãñºãÀ ‚ããÖñ¦ã.

½ããè Ôãâ‡ãñŠ¦ã ‰ãŠ. ............... ½ã£ããèË ..................Ñãñ¥ããè¦ããèË ...................... ‚ã•ãà ‡ãñŠËã ‚ãÔãî¶ã
¦¾ãã½ã£¾ãñ ½ãËã ¾ãÎãÔÌããè ÜããñãäÓã¦ã ‡ãñŠËñ ‚ããÖñ.Ôãºãºã, ½ããè Ôãâ‡ãñŠ¦ã ‰ãŠ. ................... ½ã£ããèË
..................Ñãñ¥ããè¦ããèË ½ãã¢ãã ªãÌãã Ôã½ããä¹ãæ㠇ãŠÂ¶ã Ôãâ‡ãñŠ¦ã ‰ãŠ. ............... ½ã£ããèË
..................Ñãñ¥ããè¦ããèË ÜãÀãÞãã ãäÔÌã‡ãŠãÀ ‡ãŠÀ¥¾ããÔã ¦ã¾ããÀ ‚ããÖñ.
 ¹ãì¤ãèË ºããºã¦ããè¦ã •ãÀ ‡ã슟ËñÖãè ‡ãŠãØ㪹ã¨ãñ Þãì‡ãŠãèÞãñ, Œããñ›ñ, ºã¶ããÌã› ‚ãããä¥ã ºã¶ããÌã›ãè ‚ãÔãʾããÞãñ ‚ãã¤ßî¶ã
‚ããʾããÔã ½ããè ¦¾ããÔã ¹ãî¥ãùã¥ãñ •ãºããºãªãÀ ÀãÖãè¶ã ‚ãããä¥ã ½Öã¡ãÔã Ìã㛹ã Àÿ ‡ãŠÀ¥¾ããÞãñ ‚ãããä¥ã ½ã㢾ãããäÌãÁ® Œã›Ê¾ãã¦ã
‡ãŠã¾ãªñÎããèÀ ‡ãŠãÀÌããƒÃ ‡ãŠÀ¥¾ããÞãñ ¹ãî¥ãà ÔÌãã¦ã⨾㠂ãÔãñË ‚ãããä¥ã ¾ããÔããŸãè ½ãËã •ãºããºãªãÀ £ãÀ¥¾ãã¦ã ¾ãñƒÃË.

¹ãì¤ãèË ºããºã¦ããè¦ã •ãÀ ‡ã슟ËñÖãè ‡ãŠãØ㪹ã¨ãñ Þãì‡ãŠãèÞãñ, Œããñ›ñ, ºã¶ããÌã› ‚ãããä¥ã ºã¶ããÌã›ãè ‚ãÔãʾããÞãñ ‚ãã¤ßî¶ã
‚ããʾããÔã ½ããè ¦¾ããÔã ¹ãî¥ãùã¥ãñ •ãºããºãªãÀ ÀãÖãè¶ã ‚ãããä¥ã ½Öã¡ãÔã Ìã㛹ã Àÿ ‡ãŠÀ¥¾ããÞãñ ‚ãããä¥ã ½ã㢾ãããäÌãÁ® Œã›Ê¾ãã¦ã
‡ãŠã¾ãªñÎããèÀ ‡ãŠãÀÌããƒÃ ‡ãŠÀ¥¾ããÞãñ ¹ãî¥ãà ÔÌãã¦ã⨾㠂ãÔãñË ‚ãããä¥ã ¾ããÔããŸãè ½ãËã •ãºããºãªãÀ £ãÀ¥¾ãã¦ã ¾ãñƒÃË.

½ããè „¹ãÀãñ‡ã‹¦ã ¾ããñ•ã¶ãñÞ¾ãã Ôã⪼ããæ㠼ããäÌãÓ¾ãã¦ã „°Ìã¥ããžãã ÔãÌãà ‡ãŠã¾ãªñÎããèÀ ‡ãŠãÀÌããƒÃÞ¾ãã ¹ããäÀ¥ãã½ããè ÔãÌãà ¦ããñ ›ñ
Ìã ¶ãì‡ãŠÔãã¶ã, ŒãÞãÃ, ÎãìʇãŠ, ªãÌãñ, ªâ¡ ‚ãããä¥ã ½ãâ¡ßãÞ¾ãã Ôãªãä¶ã‡ãŠã Ìã㛹㠇ãŠÀ¥¾ããÔããŸãè ûŒããñ›ãè ‚ãããä¥ã ºã¶ããÌã›
‡ãŠãØ㪹ã¨ãñ ÔããªÀ ‡ãŠÀ¥¾ãã½ããØãñ ‡ãŠãñ¥ã¦¾ããÖãè ‡ãŠãÀ¥ããÔ¦ãÌã ‡ãŠãñ¥ã¦¾ããÖãè ‡ãŠãÀÌããƒÃÔã ¹ãî¥ãùã¥ãñ ‡ãŠãÀ¥ããè¼ãî¦ã ãä‡ãâŠÌãã •ãºããºãªãÀ
‚ãÔãñ¶ã.

½ããè ¾ãã´ãÀñ ‚ãÔãñ ÔããâØã¦ããñ ‡ãŠãè, ¾ãã ¾ããñ•ã¶ãñÔã⪼ããæã Öñ àããä¦ã¹ãî¦ããê ºãâ£ã ½ã㢾ãã Ìã ½ã㢾ãã ‡ãŠã¾ãªñÎããèÀ ÌããÀÔããâÞ¾ãã
„¦¦ãÀããä£ã‡ãŠãÀãè ƒ. ÌãÀ ºãâ£ã¶ã‡ãŠãÀ‡ãŠ ‚ãÔãñË. ½ããè ¾ãã´ãÀñ ‚ãÔãñ •ãããäÖÀ ‡ãŠÀ¦ããñ ‡ãŠãè, „‡ã‹¦ã Ôãªãä¶ã‡ãŠãâÞ¾ãã Ôãâºãâ£ãã¦ã Ìã㛹ã
¹ã¨ããâÞ¾ãã ¦ãÀ¦ãîªãè Ôã⪼ããæ㠽ããè, ½ãã¢ãñ ÌããÀÔãªãÀ, „¦¦ãÀããä£ã‡ãŠãÀãè ¾ããâ¶ãã ‡ãŠãñ¥ã¦ãñÖãè ‚ããä£ã‡ãŠãÀ ãäªËñ •ãã¥ããÀ ¶ããÖãè.

Öñ ÔÌãÜããñÓã¥ãã¹ã¨ã ‚ãã•ã ã䪶ããâ‡ãŠ _____________ ½ããÖñ 201 Àãñ•ããè ãäÊãÖî¶ã ãäªÊãñ.

½ããè ................................................Þãã ½ãìËØãã / ½ãìËØããè ...................Ìã¾ã ..............

‚ãã£ããÀ ‰ãŠ½ããâ‡ãŠ ..................................... „²ããñØã ............................ ÀãÖ¥ããÀ
.........................................................................................................................
............ ¾ãñ©ãñ •ãããäÖÀ ‡ãŠÀ¦ããñ ‡ãŠãè, „¹ãÀãñ‡ã‹¦ã ½ãããäÖ¦ããè ½ã㢾ãã Ìãõ¾ããä‡ã‹¦ã‡ãŠ —ãã¶ã, ½ãããäÖ¦ããè Ìã ãäÌãÎÌããÔãã¹ã¾ãĦã Ô㦾ã Ìã
ºãÀãñºãÀ ‚ããÖñ. Œããñ›ãè ½ãããäÖ¦ããè ªñ¥¾ããÞãñ ¹ããäÀ¥ãã½ã ½ãËã ¹ãî¥ãùã¥ãñ —ãã¦ã ‚ããÖñ¦ã. ÌãÀ ãäªËñËãè ½ãããäÖ¦ããè Þãì‡ãŠãèÞããè
‚ãã¤ß¿ããÔã ½ããè ‚ãã¾ã. ¹ããè. Ôããè.1960 Þ¾ãã ‡ãŠË½ã 199 ‚ãããä¥ã 200 ‚ãããä¥ã ãä‡ãâŠÌãã ¦¾ããÌãÀ ËãØãî Öãñ¥ããžã㠂㶾ã
‡ãŠã¾ã²ããâ¶ãìÔããÀ Œã›Ê¾ãã¦ã ‚ãããä¥ã ãäÎãàãã Öãñ¥¾ããÔã •ãºããºãªãÀ ‚ãÔãñ¶ã.
ã䟇ãŠã¥ã : _____________________

ã䪶ããâ‡ãŠ: ______________________

‚ã•ãêãÀãÞãñ ¶ããÌã :__________________

‚ã•ãêãÀãÞããè ÔÌããàãÀãè :________________

‚ã•ãà ‰ãŠ½ããâ‡ãŠ : ____________________

‚ã•ãêãÀãÞãã ‚ãâØ㟿ããÞãã ŸÔãã

‚ãâØ㟿ããÞãã ŸÔãã
(„•ã̾ãã Öã¦ããÞãã
‚ãâØãŸã)
 नमन
ु ा "ए"

ळेतनप्रमाणपत्र

(Ìãñ¦ã¶ã ¹ãƽãã¥ã¹ã¨ã Ôãâºããä£ã¦ã ‡ãŠã¾ããÃÊã¾ããÞ¾ãã Êãñ›À Öñ¡ÌãÀ ‚ãÔããÌãñ)

‚ãÔãã ªãŒãÊãã ªñ¥¾ãã¦ã ¾ãñ¦ããñ ‡ãŠãè Ñããè/ Ñããè½ã¦ããè/ ‡ãìŠ ________________________ Öñ
__________________________ ¾ãã ‡ãŠã¾ããÃÊã¾ãã¦ã / ÔãâÔ©ãñ¦ã
_________________ ¾ãã ¹ãªãÌãÀ ¶ããñ‡ãŠÀãèÔã ‚ããÖñ¦ã. ¦¾ããâÞ¾ãã ¶ãñ½ã¥ãî‡ãŠãèÞãã ãäª. ________
‚ããÖñ.
¦¾ããâ¶ãã ãäª.01/04/2017 ¹ããÔãî¶ã ãäª. 31/03/2018 ¹ã¾ãĦ㠆‡ãã 12 ½ããäÖ¶¾ããâ‡ãŠÀãè¦ãã
Ìãñ¦ã¶ãã¹ããñ›ãè †‡ãã Á.________ /- †Ìã¤ãè À‡ã‹‡ãŠ½ã ‚ãªã ‡ãŠÀ¥¾ãã¦ã ‚ããÊããè ‚ããÖñ. ¾ãã À‡ãŠ½ãñ½ã£¾ãñ
ŒãÞããÃÞ¾ãã ¹ãÆãä¦ã¹ãî¦ããêÔããŸãè (Reimbursable Allowance) ªñ¥¾ãã¦ã ‚ããÊãñÊãñ ¼ã¦¦ãñ „ªã. ÜãÀ¼ãã¡ñ
¼ã¦¦ãã, Ìãõ²ããä‡ãŠ¾ã ¼ã¦¦ãã, Ìããֶ㠼㦦ãã, £ãìÊããƒÃ ¼ã¦¦ãã, ¹ãÆÌããÔ㠼㦦ãã, ãä‡ãŠ› ¼ã¦¦ãã, ƒ¦¾ããªãè ¾ããâÞãã Ôã½ããÌãñÍã
¶ããÖãè.¹ãÀâ¦ãì ºããñ¶ãÔãÔãÖ ¦¾ããâ¶ãã ªñ¥¾ãã¦ã ‚ããÊãñʾãã ƒ¦ãÀ À‡ãŠ½ããâÞãã Ôã½ããÌãñÍã ‚ããÖñ.ÌãÀãèÊã À‡ã‹‡ãŠ½ã Öãè 12
½ããäÖ¶¾ããâÔããŸãèÞããè ‚ãÔãî¶ã ¦¾ãã¶ãìÔããÀ ¦¾ããâÞãã ÔãÀãÔãÀãè ½ãããäÔã‡ãŠ ¹ãØããÀ Á.________/- ‚ããÖññ.

ã䟇ãŠã¥ã :- ________
ã䪶ããâ‡ãŠ :-________
¶ããÌã :-
Öìÿã, ÔãâÔ©ãñÞã㠹㦦ãã Ìã ãäÔãÊã :-
‡ãŠã¡Ã /‡ãŠ¹ãâ¶ããèÞ¾ãã
Ô›ù½¹ãÞãã Ìãã¹ãÀ
‡ãŠÁ¶ã ÊããÌã¥ãñ

ãäÎã‡ã‹‡ãŠã
 नमन
ु ाक्रमाांक - क

(‚ã•ãêãÀ ¹ã¦ããè /¹ã¦¶ããè ºãñÀãñ•ãØããÀ ‚ã©ãÌãã ÔÌã¾ãâÀãñ•ãØããÀãè¦ã ¹ãÀ¦ãì ‚ãã¾ã‡ãŠÀªã¦ãã ¶ãÔãʾããÔã

¹ã¦ããè /¹ã¦¶ããè ¶ãñ ãä¦ãÞãñ /¦¾ããÞãñ „¦¹ã¸ã ªÍãÃãäÌã¥ããÀñ ÔÌãÜããñÓã¥ãã¹ã¨ããÞãã ¶ã½ãì¶ãã)

ÔÌãÜããñÓã¥ãã¹ã¨ã

½ããè Ñããè /Ñããè½ã¦ããè /‡ãìŠ________________________________________ Ìã¾ã______ ÌãÓãó

¼ããÀ¦ããè¾ã ÀãÖ¥ããÀ___________________________________ ¹ãÆãä¦ã—ãã¹ãîÌãÇãŠ

•ããÖãèÀ ‡ãŠÀ¦ããñ/‡ãŠÀ¦ãñ ‡ãŠãè, ½ããè ½ãã¢ãñ ¹ã¦ããè /½ãã¢ããè ¹ã¦¶ããè Ñããè/ Ñããè½ã¦ããè /_____________________
¾ããâ¶ããè¹ãì¥ãñ ½ãâ¡ßãÞ¾ãã Ôãâ‡ãñŠ¦ã ‰ãŠ ____________ ã䟇ãŠã¥ã __________ ¾ãã ¾ããñ•ã¶ãñ‚ãâ¦ãØãæã ã䪶ããâ‡ãŠ
_____________ Þ¾ãã Ô©ãããä¶ã‡ãŠ Ìãð¦¦ã¹ã¨ãã¦ããèÊã •ããÖãèÀã¦ããè¶ãìÔããÀ ‚ã•ãà ‡ãñŠÊãã ‚ãÔãî¶ã ÔãªÀÞãã ‚ã•ãÃ
‰ãŠ.__________ ‚ããÖñ.

½ããè Ñããè /Ñããè½ã¦ããè /‡ãìŠ________________________________________

¹ãÆãä¦ã—ãã¹ãîÌãÇ㊠‚ãÔãñ •ããÖãèÀ ‡ãŠÀ¦ããñ /‡ãŠÀ¦ãñ ºãñÀãñ•ãØããÀ ‚ããÖñ / ½ã㢾ãã ÔÌã¦ã:Þãã ______________________
̾ãÌãÔãã¾ã ‚ããÖñ. ÔãªÀ ̾ãÌãÔãã¾ãã¦ãî¶ã ãä½ãßãÊãñÊãñ ½ããØããèÊã ½ããäÖ¶¾ãã¦ããèÊã ½Ö¥ã•ãñÞã (ã䪶ããâ‡ãŠ 01/04/2017 ¹ããÔãî¶ã
31/03/2018 ) ¾ãã ‡ãŠãÊããÌã£ããèÞãñ „¦¹ã¸ã Á¹ã¾ãñ Á.___________/- †Ìã¤ñ ‚ããÖñ.

½ããè ¹ãÆãä¦ã—ãã¹ãîÌãÇ㊠‚ãÔãñ •ããÖãèÀ ‡ãŠÀ¦ããñ /‡ãŠÀ¦ãñ ‡ãŠãè ½ãã¢ãã ¹ãù¶ã ‰ãŠ½ããâ‡ãŠ
________________________ ‚ãÔãî¶ã ½ããè ‚ãã¾ã‡ãŠÀªã¦ãã ¶ããÖãè.

½ããè ¹ãÆãä¦ã—ãã¹ãîÌãÇ㊠‚ãÔãñ •ããÖãèÀ ‡ãŠÀ¦ããñ /‡ãŠÀ¦ãñ ‡ãŠãè, ÌãÀãèÊã ½ã•ã‡ãîŠÀ ŒãÀã Ìã ºãÀãñºãÀ ‚ãÔ㦾㠟ÀʾããÔã ãä‡ãâŠÌãã
¹ãŠÀ‡ãŠ ‚ãã¤ßʾããÔã ÔãªÀ ‚ã•ãà Àÿ ‡ãŠÀ¥¾ããÞãã ¦ãÔãñÞã Ìã㛹㠇ãŠÀ¥¾ãã¦ã ‚ããÊãñÊããè Ôãªãä¶ã‡ãŠã Àÿ ‡ãŠÀ¥¾ããÞãã ¦ãÔãñÞã
½ã㢾ãã ãäÌãÁ® ‡ãŠã¾ãªñÍããèÀ ‡ãŠãÀÌããƒÃ ‡ãŠÀ¥¾ããÞãã ‚ããä£ã‡ãŠãÀ ¹ãì¥ãñ ½ãâ¡ß/ ½Öã¡ã ¾ããâ¶ãã ÀããäÖÊã.
 ÔãªÀ ¹ãÆãä¦ã—ãã¹ã¨ãã¦ã ãäªÊãñÊããè ½ãããäÖ¦ããè ½ã㢾ãã ÔãâãØ㥾ãã¹ãƽãã¥ãñ ŒãÀãè Ìã Ô㦾㠂ãÔãî¶ã ¦¾ããÞ¾ãã Ô㦾ã¦ãñ‡ãŠÀãè¦ããÞããè
Ôããàã ½Ö¥ãî¶ã ¦¾ããÌãÀ ½ããè ½ãã¢ããè ÔÌããàãÀãè ‡ãŠÀãè¦ã ‚ããÖñ.

½ããè__________________ Ñããè ____________________________ ¾ããâÞãã

½ãìÊãØãã/½ãìÊãØããè Ìã¾ã _____________‚ãã£ããÀ‡ãŠã¡Ã ‰ãŠ. ___________________ ̾ãÌãÔãã¾ã

___________________ ÀãÖ¥ããÀ ________________________ ÜããñãäÓã¦ã ‡ãŠÀ¦ããñ /‡ãŠÀ¦ãñ

‡ãŠãè, ÌãÀãèÊã ÔãÌãà ½ãããäÖ¦ããè ½ã㢾ãã Ìãõ¾ããä‡ã‹¦ã‡ãŠ —ãã¶ã ½ãããäÖ¦ããè Ìã ãäÌãÍÌããÔãã¹ã¾ãĦ㠺ãÀãñºãÀ ‚ããÖñ. ÔãªÀ ½ãããäÖ¦ããè Œããñ›ãè

‚ãã¤ßî¶ã ‚ããʾããÔã ¼ããÀ¦ããè¾ã ªâ¡ ÔãâãäÖ¦ãã 1960 ‡ãŠÊã½ã 199 Ìã 200 Ì㠂㶾ã /Ôãâºãâãä£ã¦ã ‡ãŠã¾ã²ãã¶ãìÔããÀ

½ã㢾ããÌãÀ Œã›Êãã ¼ãÀÊãã •ããƒÃÊã Ìã ¦¾ãã¶ãìÔããÀ ½ããè ãäÍãàãñÔã ¹ãã¨ã Àããäֶ㠾ããÞããè ½ãÊãã ¹ãî¥ãà •ãã¥ããèÌã ‚ããÖñ.

Öñ ÔÌãÜããñÓã¥ãã¹ã¨ã ‚ãã•ã ã䪶ããâ‡ãŠ _____________ ½ããÖñ 201 Àãñ•ããè ãäÊãÖî¶ã ãäªÊãñ.

ã䟇ãŠã¥ã : _____________________

ã䪶ããâ‡ãŠ: ______________________

‚ã•ãêãÀãÞãñ ¹ã¦ããè /¹ã¦¶ããèÞããè ÔãÖãè :________________

‚ã•ãêãÀãÞãñ ¶ããÌã :__________________

‚ã•ãà ‰ãŠ½ããâ‡ãŠ : ____________________

›ãè¹ã :- ‚ã•ãêãÀãÞããè ¹ã¦¶ããè/ ¹ã¦ããè ºãñÀãñ•ãØããÀ ‚ãÔãʾããÔã „¦¹ã¸ã "ãä¶ãÀâ‡ãŠ" ãäÊãÖãÌãñ. ¦ãÔãñÞã ¹ãù¶ã ‰ãŠ½ããâ‡ãŠ ¶ãÔãʾããÔã
"ãä¶ãÀâ‡ãŠ" ãäÊãÖãÌãñ

‚ã•ãêãÀãÞãã ‚ãâØ㟿ããÞãã ŸÔãã ‚ãâØ㟿ããÞãã ŸÔãã

(„•ã̾ãã Öã¦ããÞãã
‚ãâØãŸã)
 नमन
ु ाक्रमाांक - ई

‚ã•ãêãÀ Ìã ¦¾ããâÞãñ ¹ã¦ããè/ ¹ã¦¶ããè ¾ããâÞ¾ãã ¶ããÌããâÌãÀ ¾ããñ•ã¶ãã Öÿãè¦ã ÜãÀ ¶ãÔãʾããºããºã¦ã ÔÌãÜããñÓã¥ãã¹ã¨ã

½ããè Ñããè /Ñããè½ã¦ããè /‡ãìŠ_______________________________ Ìã¾ã______ ÌãÓãó

¼ããÀ¦ããè¾ã ÀãÖ¥ããÀ________________________________________________ ¹ãÆãä¦ã—

ãã¹ãîÌãÇãŠ

•ããÖãèÀ ‡ãŠÀ¦ããñ/‡ãŠÀ¦ãñ ‡ãŠãè, ½ããè ¹ãÆãä¦ã—ãã¹ãîÌãÇ㊠‚ãÔãñ ãäÊãÖî¶ã ªñ¦ããñ/ªñ¦ãñ ‡ãŠãè, ½ãã¢ãñ

¹ã¦ããè/¹ã¦¶ããèÞ¾ãã ãä‡ãâŠÌãã ½ã㢾ãã ‚ã—ãã¶ã ½ãìÊããâÞ¾ãã ¶ããÌãñ ¹ãì¥ãñ /ãä¹ãâ¹ãÀãè ãäÞãâÞãÌã¡ ½ãÖã¶ãØãÀ¹ãããäÊã‡ãŠã ¾ããâÞãñ Öÿãè¦ã ½ããÊã‡ãŠãè

¦ã¦ÌããÌãÀ, ¼ãã¡ñ ŒãÀñªãè ¹ã®¦ããèÌãÀ ‚ã©ãÌãã ¶ããòª¥ããè‡ãðŠ¦ã ÔãÀ‡ãŠãÀãè ØãðÖãä¶ã½ããÃ¥ã ÔãâÔ©ãñÞãã ÔãªÔ¾ã ½Ö¥ãì¶ã ¹ãì¥ãñ /ãä¹ãâ¹ãÀãè

ãäÞãâÞãÌã¡ ½ãÖã¶ãØãÀ¹ãããäÊã‡ãŠã Öÿãè¦ã ½Öã¡ã¶ãñ ãäÌã¦ãÀãè¦ã ‡ãñŠÊãñÊãã Ìã Œãã•ãØããèãäÀ¦¾ãã Ôãâ¹ããªãè¦ã ‡ãñŠÊãñÊãã ãä¶ãÌããÔããè Øããßã

/ãä¶ãÌããÔããè ¼ãîŒãâ¡ ¶ããÖãè.

½ããè ¹ãÆãä¦ã—ãã¹ãîÌãÇ㊠‚ãÔãñ ãäÊãÖî¶ã ªñ¦ããñ /ªñ¦ãñ ‡ãŠãè,‚ã•ãà ‰ãŠ. ____________________ ‡ãŠãñ¡ ¶ãâ

_____________ Øã› /¹ãÆÌãØãà _____________ ã䪶ããâ‡ãŠ _____________ Àãñ•ããè ‚ã•ãà ‡ãñŠÊãñÊãã

‚ãÔãî¶ã ¾ãã¹ãîÌããê ½Öã¡ãÞ¾ãã ‡ãŠãñ¥ã¦¾ããÖãè ¾ããñ•ã¶ãñ ‚ãâ¦ãØãæã ãä¶ãÌããÔããè Øããßã/ ãä¶ãÌããÔããè ¼ãîŒãâ¡ãÞãñ Ìã㛹㠽ãã¢ãñ, ½ã㢾ãã ¹ã¦ããè/

¹ã¦¶ããèÞ¾ãã ãä‡ãâŠÌãã ½ã㢾ãã ‚ã—ãã¶ã ½ãìÊããâÞ¾ãã ¶ããâÌãñ ¢ããÊãñÊãñ ¶ããÖãè.

 ½ããè ÔãªÀÞãñ Ô㦾㠹ãÆãä¦ã—ãã¹ã¨ãã¦ã ãäªÊãñÊããè ½ãããäÖ¦ããè ½ã㢾ãã ÔãâãØ㥾ãã¹ãƽãã¥ãñ ŒãÀãè Ìã Ô㦾㠂ãÔãî¶ã ¦¾ããÞ¾ãã

Ô㦾ã¦ãñ‡ãŠÀãè¦ããÞããè Ôããàã ½Ö¥ãî¶ã ¦¾ããÌãÀ ½ããè ½ãã¢ããè ÔãÖãè ‡ãŠÀãè¦ã ‚ããÖñ.

½ããè__________________ Ñããè ____________________________ ¾ããâÞãã

½ãìÊãØãã/½ãìÊãØããè Ìã¾ã _____________‚ãã£ããÀ‡ãŠã¡Ã ‰ãŠ. ___________________ ̾ãÌãÔãã¾ã

___________________ ÀãÖ¥ããÀ ________________________ ÜããñãäÓã¦ã ‡ãŠÀ¦ããñ /‡ãŠÀ¦ãñ

‡ãŠãè, ÌãÀãèÊã ÔãÌãà ½ãããäÖ¦ããè ½ã㢾ãã Ìãõ¾ããä‡ã‹¦ã‡ãŠ —ãã¶ã ½ãããäÖ¦ããè Ìã ãäÌãÍÌããÔãã¹ã¾ãĦ㠺ãÀãñºãÀ ‚ããÖñ. ÔãªÀ ½ãããäÖ¦ããè Œããñ›ãè

‚ãã¤ßî¶ã ‚ããʾããÔã ¼ããÀ¦ããè¾ã ªâ¡ ÔãâãäÖ¦ãã 1960 ‡ãŠÊã½ã 199 Ìã 200 Ì㠂㶾ã /Ôãâºãâãä£ã¦ã ‡ãŠã¾ã²ãã¶ãìÔããÀ

½ã㢾ããÌãÀ Œã›Êãã ¼ãÀÊãã •ããƒÃÊã Ìã ¦¾ãã¶ãìÔããÀ ½ããè ãäÍãàãñÔã ¹ãã¨ã Àããäֶ㠾ããÞããè ½ãÊãã ¹ãî¥ãà •ãã¥ããèÌã ‚ããÖñ.

Öñ ÔÌãÜããñÓã¥ãã¹ã¨ã ‚ãã•ã ã䪶ããâ‡ãŠ _____________ ½ããÖñ 201 Àãñ•ããè ãäÊãÖî¶ã ãäªÊãñ.

ã䟇ãŠã¥ã : _____________________

ã䪶ããâ‡ãŠ: ______________________

‚ã•ãêãÀãÞãñ ÔãÖãè :________________

‚ã•ãêãÀãÞãñ ¶ããÌã :__________________

‚ã•ãà ‰ãŠ½ããâ‡ãŠ : ____________________

‚ã•ãêãÀãÞãã ‚ãâØ㟿ããÞãã ŸÔãã

‚ãâØ㟿ããÞãã ŸÔãã
(„•ã̾ãã Öã¦ããÞãã
‚ãâØãŸã)