evsjv‡`k nvDm wewìs dvBbvÝ K‡c©v‡ikb

22, cyivbv cëb, XvKv-1000| Qwe

miKvix Kg©Pvix‡`i Rb¨ d¬¨vU F‡Yi Av‡e`b dig

1| Av‡e`bKvixi bvg (evsjvq) t ...........................................................................................................
(Bs‡iRx‡Z) t ...........................................................................................................
2| wcZvi bvg (evsjvq) t ...........................................................................................................
(Bs‡iRx‡Z) t ...........................................................................................................
3| gvZvi bvg (evsjvq) t ...........................................................................................................
(Bs‡iRx‡Z) t ...........................................................................................................
4| ¯^vgxi/¯¿x'i bvg (evsjvq) t ...........................................................................................................
(Bs‡iRx‡Z) t ...........................................................................................................
5| Rb¥ ZvwiL t ...........................................................................................................
6| eZ©gvb wVKvbv (evsjvq) t ..................................................................................................
..................................................................................................
(Bs‡iRx‡Z) t ..................................................................................................
..................................................................................................
7| ¯’vqx wVKvbv (evsjvq) t ..................................................................................................
..................................................................................................
(Bs‡iRx‡Z) t ..................................................................................................
..................................................................................................
(wVKvbv, †dvb b¤^i ev B-‡gBj cwieZ©b n‡j Zv wjwLZfv‡e K‡c©v‡ikb‡K Rvbv‡Z n‡e)
8| †mj ‡dvb b¤^i t .................................................................................................................
9| j¨vÛ †dvb b¤^i t Awdm : .............................................. evmv : ................................................
10| E-mail Address t ..................................................................................................................
11| RvZxq cwiPq cÎ b¤^i t ................................................................................................................
12| cvm‡cvU© b¤^i (hw` _v‡K) t .............................................................................................................
13| e-TIN b¤^i t ..................................................................................................................
14| PvKzixi weeiY t Awd‡mi bvg (wVKvbvmn) :
i) (gš¿Yvjq/wefvM/Awa`ßi/cwi`ßi) ......................................................................
ii) c`ex : .................................., iii) wRwcGd............, iv) cwiwPwZ b¤^i : .............
v) PvKzix‡Z †hvM`v‡bi ZvwiL : ..................., vi) eZ©gvb c‡` †hvM`v‡bi ZvwiL: ............
vii) Aemi MÖn‡Yi ZvwiL : ....................................................................................
viii) †MÖW : .............................., ix) †eZb †¯‹j : ................................................
x) g~j †eZb : ..........................., xi) me©‡gvU †eZb (Gross pay) : ........................
xii) AvnwiZ †eZb (Take home pay) : ...............................................................
15| cÖ¯ÍvweZ d¬¨vU/feb wbg©vYKvix cÖwZôv‡bi bvg Ges cÖK‡íi bvg (cÖ‡hvR¨ †ÿ‡Î) t ..........................................
.....................................................................................................................
16| d¬¨vU fe‡bi weeiY t KZ Zjv : ..............................., d¬¨v‡Ui msL¨v : ................................................
17| cÖ¯ÍvweZ d¬¨v‡Ui cwiwPwZ t AvqZb : ........................., KZ Zjvi d¬¨vU: ................, d¬¨vU b¤^i : ...............
18| eZ©gv‡b d¬¨v‡Ui wbg©vY KvR †Kvb ch©v‡q Av‡Q t ...................................................................................
19| Rwgi gvwjKvbvi aiY t .................................................................................................................
20| ‡h Rwgi Dci d¬¨vU wbgv©Y Kiv n‡”Q Zvi Zdwmj t
†Rjv...................................... _vbv...............................
†gŠRv.................................... ‡R.Gj bs........................
wm.Gm. LwZqvb - .................. wm.Gm. `vM bs ....................
Gm.G LwZqvb-..................... Gm. G. `vM bs ....................
Pjgvb cvZv-2
 cvZv-2

Avi. Gm. LwZqvb - ............... Avi. Gm. `vM bs .........................

we.Gm./we.Avi.Gm LwZqvb- ................. we. Gm./we.Avi.Gm. `vM bs ................
bvgRvix LwZqvb- ................... bvgRvix `vM bs ...........................
†cŠi †nvwìs b¤^i (hw` _v‡K) .....................................................
Rwgi cwigvY- ........................................................................
†m±i/†mKkb bs ............... eøK bs ............... †ivW bs.................
cøU bs.......................... Rwgi cwigvY........................................
GjvKvi bvg -..........................................................................
fe‡bi eZ©gvb ‡PŠnÏx t Dˇi t .................. `w¶‡Y t....................
c~‡e© t.................... cwð‡g t....................
21| Aby‡gvw`Z bK&kvi ¯§viK b¤^i: ....................................................., bK&kv Aby‡gv`‡bi ZvwiL: .................
bK&kv Aby‡gv`bKvix KZ…©cÿ : ...........................................................................................................
22| wbg©vY KvR Kiv Av‡Q wK-bv t.............................................................................................................
wbg©vY KvR Kiv _vK‡j B‡Zvg‡a¨ KZ UvKv wewb‡qvM Kiv n‡q‡Q : ..............................................................
23| eÜK ivLvi Rb¨ AvbycvwZK Rwgi cwigvY t .........................................................................................
24| d¬¨v‡Ui †gvU g~j¨ t ....................................................................................................................
25| (K) Av‡e`bK…Z F‡Yi cwigvY ............................ (K_vq) ...........................................................UvKv|
(L) cwi‡kva †gqv` ............................................... eQi|
26| cwiev‡ii †gvU m`m¨ KZRb?
m`m¨M‡Yi bvg eqm m¤úK©
(1)
(2)
(3)
(4)

27| B‡Zvc~‡e© Ab¨ †Kvb Avw_©K cÖwZôvb n‡Z †Kvb FY MÖnY K‡i‡Qb wK? MÖnY K‡i _vK‡j wb¤œwjwLZ weeiY w`b t
M„nxZ
Avw_©K my‡`i cwi‡kva F‡Yi
UvKvi MÖn‡Yi D‡Ïk¨ Rvgvb‡Zi Z_¨
cÖwZôv‡bi bvg nvi †gqv` e¨v‡jÝ
cwigvY

28| Avcwb Ab¨ Kv‡iv F‡Yi Rb¨ GB e¨vsK/K‡c©v‡ik‡b Rvwgb`vi Av‡Qb wK? _vK‡j wb¤œwjwLZ weeiY w`b t
(1) FY †KBm b¤^i : ..............................., F‡Yi cwigvY : ............................................
(2) my` nvi : ........................................., cwi‡kva †gqv` : ..........................................
29| Avcbvi cwiev‡ii †Kvb m`m¨ GB K‡c©v‡ik‡bi wbKU n‡Z †Kvb FY MÖnY K‡i‡Qb wK A_ev F‡Yi Rb¨ Av‡e`b
K‡i‡Qb wK? K‡i _vK‡j wb¤œwjwLZ weeiY w`b t
(1) FY †KBm b¤^i : ..............................., F‡Yi cwigvY : ............................................
(2) Avcbvi mv‡_ m¤úK© : .............................................................................................

30| Avcwb Ab¨ †Kvb Z_¨ ev weeiY w`‡Z PvB‡j Zv GLv‡b wjwce× Kiæb t

Avwg GB g‡g© †NvlYv Kwi‡ZwQ †h, Dc‡i ewY©Z Z_¨vw` Avgvi Ávb I wek¦vm g‡Z mZ¨ Ges mwVK| Avwg †Kvb
wKQz †Mvcb Kwi bvB|

Av‡e`bKvixi ¯^vÿi