wU‡fvjx G¨vcv‡ijm wjwg‡UW|

cøU-G,102 wewmK wkíbMix, U½x, MvRxcyi|

eqm I mÿgZvi cÖZ¨qbcÎ

eqm I mÿgZvi cÖZ¨qb cÎ eqm I mÿgZvi cÖZ¨qb cÎ

1| µwgK bs: 1| µwgK bs:
ZvwiL: ZvwiL:
2| bvg:
3| wcZvi bvg: Avwg GB g‡g© cÖZ¨qb Kwi‡ZwQ †h

(bvg):...........................................................wcZv:..............................................

gvZv:............................................................wVKvbv:.............................................

.......................................................................‡K Avwg cixÿv KwiqvwQ|

4| gvZvi bvg:
5| wj½ wZwb cÖwZôv‡b wbhy³ nB‡Z B”QzK, Ges Avgvi cixÿv nB‡Z GBiæc cvIqv wMqv‡Q
†h Zvnvi

eqm........................ermi Ges wZwb cÖwZôv‡b cÖvß eq¯‹/ wK‡kvi wnmv‡e wbhy³

nBevi †hvM¨|
6| ¯’vqx wVKvbv: Zvnvi mbv³Ki‡bi wPû:
7| A¯’vqx / †hvMv‡hv‡Mi wVKvbv:

8| Rb¥ mb`/ wkÿv mb` Abymv‡i eqm/ Rb¥ ZvwiL:

9| ˆ`wnK mÿgZv:
10| mbv³Kib wPû:
11| g`Kvm³ Av‡Q wKbv
mswkøó e¨w³i †iwR÷vW© wPwKrm‡Ki mswkøó e¨w³i †iwR÷vW© wPwKrm‡Ki ¯^vÿi
¯^vÿi/wUcmwn ¯^vÿi ¯^vÿi/ wUcmwn