evsjv‡`k BDwbfvwm©wU Ae cÖ‡dkbvjm&

KgvÛ¨v›U KZ©„K
wbqwgZ/wi‡UK/gv‡bvbœqb
mZ¨vwqZ cvm‡cvU©
mvBR Qwe cix¶vi †ivj b¤^i: __________
(cix¶v wbqš¿K Awdm KZ…K
© c~iYxq)

cix¶vq AskMÖn‡Yi Av‡e`bcÎ

weIwWGm wel‡qi-------------------------------------- el© cix¶v---------------------gvm-------------------mb

wefv‡Mi bvg:--------------------------------- evsjv‡`k BDwbfvwm©wU Ae cÖ‡dkbvjm& Gi

‡kªYx †ivj bs--------------------------------- wbeÜb bs--------------------------------
wk¶vel©:------------------------------------- wk¶vel©:---------------------------------

1| cix¶v_©xi c~Y© bvg (evsjvq):--------------------------------------------------------------------

(GmGmwm /mggvb mb` Abyhvqx Bs‡iwR‡Z eo A¶‡i):----------------------------------------------------------
2| wcZvi bvg:-------------------------------------------------------------------------------------
3| gvZvi bvg:-------------------------------------------------------------------------------------
4| AwffveK/¯^vgxi bvg (cÖ‡hvR¨ †¶‡Î):-----------------------------------------------------------
cix¶vq AeZxb© nBevi welq/welqmg~n (†Kvm©/cÎ bs mn)
µ: bs welq/c‡Îi †KvW bs welq/c‡Îi bvg cÎ
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eivei
cix¶v wbqš¿K
evsjv‡`k BDwbfvwm©wU Ae cÖ‡dkbvjm&
wgicyi †mbvwbevm, XvKv-1216|
Rbve,
Avwg Avmbœ weIwWGm wel‡qi-------------------- el© cix¶v------------------gvm---------------------- m‡bi
cix¶vq wbqwgZ/AwbqwgZ/gv‡bvbœqb/wi‡UK cix¶v_©x wn‡m‡e AskMÖn‡Yi R‡b¨ AbygwZ cÖv_©bv Kwi‡ZwQ| Avwg A½xKvi Kwi‡ZwQ
†h, Avgvi cix¶v msµvšÍ e¨vcv‡i weBDwcÕi wmwÛ‡KU ev ZrKZ…©K ¶gZvcÖvß Awdmv‡ii wm×všÍ P~ovšÍ ewjqv gvwbqv wb‡Z eva¨
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ZvwiL:....................20.............. ..........................................
cix¶v_x©i ¯^v¶i
cÖZ¨qbcÎ
Avwg cÖZ¨qb Kwi‡ZwQ †h, DwjøwLZ cix¶v_©xi Kvh©vw` m‡šÍvlRbK Ges Avwg Zvnv‡K Avmbœ weIwWGm wel‡qi ---------------
el© cix¶v-------------gvm ---------- m‡bi cix¶vq wbqwgZ/AwbqwgZ/gv‡bvbœqb/wi‡UK cix¶v_©x wn‡m‡e AskMÖn‡Yi
AbygwZi Rb¨ mycvwik Kwi‡ZwQ| Avwg AviI hvPvB Kwiqv †`wLqvwQ Zvnvi M„nxZ welq/†Kvm©mg~n mwVKfv‡e wjwLZ Av‡Q| GB
cix¶v_x©i K¬v‡k Dcw¯’wZi nvi..............%..................................(K_vq)|

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ZvwiL KgvÛ¨v›U Gi ¯^v¶i I wmj
 cix¶v_©x‡K wb‡gœi Z_¨vejx ¯^n‡¯Í c~iY Kwi‡Z nB‡e

1| ¯’vqx wVKvbv: MÖvg/moK:.............................evox bs..........................WvKNi..................................

†cv÷ †KvW bs ...................................Dc‡Rjv.....................................†Rjv.........................................

2| Rb¥ ZvwiL : (GmGmwm mvwU©wd‡KU Abyhvqx).............................................................................................

3| cix¶v erm‡ii 1jv Rvbyqvwi 20................m‡b eqm.....................ermi.......................gvm....................w`b
4| RvZxqZv .................................................ag©......................................eY©/m¤cÖ`vq...............................
5| GmGmwm ev mggvb cix¶v cv‡mi weeiY: †evW©.........................................cv‡ki mb.....................................
†ivj b¤^i .....................................cÖvß wefvM/wRwcG................................MÖæc........................................
6| GBPGmwm ev mggvb cix¶v cv‡mi weeiY: †evW©.........................................cv‡ki mb...................................
†ivj b¤^i .....................................cÖvß wefvM/wRwcG................................MÖæc........................................

7| wek¦we`¨vj‡qi †Kv‡bv cix¶vq ewn¯‹…Z nBqv _vwK‡j kvw¯Íi †gqv` D‡jøL Kwi‡Z nB‡e:
cix¶vi bvg I mb: ........................................................................†ivj bs.........................................
kvw¯Íi †gqv` 20..............................mb nB‡Z ...................................mb ch©šÍ

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cix¶v_x©i ¯^v¶i I ZvwiL
eZ©gvb wVKvbv......................................
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†gvevBj ‡dvb bs..................................

Avwg cÖZ¨qb Kwi‡ZwQ †h, cix¶v_x© cÖwZôv‡bi mKj kZ©vewj cvjb Kwiqv‡Q Ges †m mr Pwi‡Îi AwaKvix| Avgvi Rvbvg‡Z
Av‡e`bc‡Îi mKj weeiY mZ¨| cix¶v_x© KZ…K
© wek¦we`¨vj‡qi cvIbv cix¶vi wd/b¤^icÎ wd/mvgwqK mb` wd/Ab¨vb¨ wd eve`
UvKv..........................................Rgv Kiv n‡q‡Q| Av‡e`bKvix‡K weIwWGm wel‡qi-------------el© cix¶v----------------
gvm ----------- m‡bi cix¶vq wbqwgZ/AwbqwgZ gv‡bvbœqb/wi‡UK cix¶v_©x wn‡m‡e AskMÖn‡Yi AbygwZ †`Iqv hvB‡Z cv‡i|

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wbix¶vKvixi ¯^v¶i I ZvwiL KgvÛ¨v›U ¯^v¶i I wmj

2
 evsjv‡`k BDwbfvwm©wU Ae cÖ‡dkbvjm&
KgvÛ¨v›U KZ©„K
wbqwgZ/wi‡UK/gv‡bvbœqb
mZ¨vwqZ cvm‡cvU©
mvBR Qwe cix¶vi †ivj b¤^i: __________

cÖ‡ekcÎ
weIwWGm wel‡qi -------------------------------el© cix¶v----------------------------gvm--------------------mb

wefv‡Mi bvg:--------------------------------- evsjv‡`k BDwbfvwm©wU Ae cÖ‡dkbvjm& Gi

‡kªYx †ivj bs--------------------------------- wbeÜb bs--------------------------------
wk¶vel©:------------------------------------- wk¶vel©:---------------------------------

1| cix¶v_©xi c~Y© bvg (evsjvq):--------------------------------------------------------------------

(GmGmwm /mggvb mb` Abyhvqx Bs‡iwR‡Z eo A¶‡i):----------------------------------------------------------
2| wcZvi bvg:-------------------------------------------------------------------------------------
3| gvZvi bvg:-------------------------------------------------------------------------------------
4| AwffveK/¯^vgxi bvg (cÖ‡hvR¨ †¶‡Î):-----------------------------------------------------------
cix¶vq AeZxb© nBevi welq/welqmg~n (†Kvm©/cÎ bs mn)
µ: bs welq/c‡Îi †KvW bs welq/c‡Îi bvg cÎ
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cix¶v_x©i ¯^v¶i:.......................................................

cix¶v Avi¤¢ nBevi ZvwiL:..........................................

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cix¶v wbqš¿K
evsjv‡`k BDwbfvwm©wU Ae cÖ‡dkbvjm&

we: `ª: 1| KgvÛ¨v›U cix¶v_x©i d‡Uv mZ¨vqb Kwi‡eb|

2| KgvÛ¨v›U KZ…©K cÖZ¨vwqZ Z_¨vewj P~ovšÍ ewjqv we‡ewPZ nB‡e|
3| cix¶vi cÎ/†Kv‡m© †Kv‡bv KvUvKvwU ev NlvgvRv Pwj‡e bv|

(Aci c„ôvq `ªóe¨)

 cix¶v_x©‡`i Rb¨ wb‡`©kvewj
1| evsjv‡`k BDwbfvwm©wU Ae cÖ‡dkbvjm& nB‡Z Bmy¨K…Z cÖ‡ekcÎ Qvov †Kv‡bv cix¶v_x©‡K cixÿv n‡j
cÖ‡ek Kwi‡Z †`Iqv nB‡e bv|
2| cwi`k©‡Ki ¯^v¶i wenxb DËicÎ MÖnY‡hvM¨ b‡n|
3| cix¶vi mgqm~wP I ¯’vb cix¶v_x©‡K wbR `vwq‡Z¡ Rvwbqv wb‡Z nB‡e|
4| cix¶vi n‡j cÖ‡ekcÎ, cwiPqcÎ, Kvwj, Kjg, †cwÝj, R¨vwgwZe·, mswkøó wefv‡Mi Aby‡gvw`Z
K¨vjKz‡jUi (cÖ‡qvR‡b) I UvKv cqmv e¨ZxZ cix¶v_x©i m‡½ Ab¨ †Kv‡bv wKQy _vKv A‰ea ewjqv MY¨
nB‡e|
5| cix¶v‡K‡›`ªi AvBb-k„•Ljv f½Kvix cix¶v_x©‡`i weiæ‡× Dchy³ AvBbvbyM e¨e¯’v MÖnY Kiv nB‡e|
6| cix¶vn‡ji cwi`k©K I mswkøó Awdmvi-Bb-PvR© KZ…©K Av‡ivwcZ wb‡`©kvewj h_vh_fv‡e cix¶v_x©‡K
gvwbqv Pwj‡Z nB‡e|
7| cix¶vi LvZvi Kfvi c„ôvq g~w`ªZ wb‡`©kvewj cix¶v_x©MY KZ…©K h_vh_fv‡e cvjbxq|
8| cix¶vi n‡j a~gcvb m¤ú~Y©iƒ‡c wbwl× Ges kvw¯Íg~jK Aciva|
9| DËic‡Îi Dci cix¶v_x©‡`i bvg-avg wjLv Pwj‡e bv|
10| cix¶vi n‡j †gvevBj †dvb I B‡jKUªwbK wWfvBm wbqv cÖ‡ek Kiv hvB‡e bv|
11| cix¶v Avi‡¤¢i ci GK N›Uv AwZevwnZ nBevi c~‡e© †Kv‡bv cix¶v_x© nj Z¨vM Kwi‡Z ev LvZv Rgv
w`‡Z cvwi‡e bv|
12| mKj c‡Îi cix¶vi Rb¨ GKB cÖ‡ekcÎ e¨eüZ nB‡e|
13| cix¶v Avi¤¢ nBevi Avav N›Uv c‡i †Kv‡bv cix¶v_x© n‡j cÖ‡ek Kwi‡Z cvwi‡e bv|