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bvg (evsjvq) FEMALE MALE

(Please leave a box after each

NAME word. Spelling as National ID.)

NID PASSPORT

FATHER

MOTHER

SPOUSE-¯^vgx/ ¯¿x (IF APPLICABLE)

PRESENT ADDRESS (cÖevmx n‡j we‡`‡ki wVKvbv)

PHONE MOBILE RES.

PERMANENT ADDRESS

E-MAIL

BIRTHDAY AGE MARRIAGE DAY

RELIGION EDUCATION

OCCUPATION DESIGNATION

INSTITUTION/ WORK PLACE (IN DETAILS)

ˆ`wnK/ gvbwmK/ †ckvMZ/ cvwievwiK/ cvwicvwk¦©K/ Ab¨ †Kv‡bv Amyweav (hw` _v‡K)

REF. NAME RELATION REG. NO. PHONE

Avwg cÖwZÁv KiwQ †h, cÖwk¶YKv‡j †hvM dvD‡Ûk‡bi wbqgvewj Avwg cy‡ivcywi †g‡b Pje, wbqwgZ K¬v‡m AskMÖnY Kie Ges K¬v‡mi
cÖwZwU wb‡`©k Abyaveb K‡i Zv cvjb Kivi AvšÍwiK cÖ‡Póv Pvjve| cÖwk¶Y †k‡l AwR©Z gvbwmK I AZxw›`ªq kw³‡K mZK©Zvi mv‡_
wb‡Ri I gvbeZvi Kj¨v‡Y Kv‡R jvMve| AwR©Z gvbwmK I AZxw›`ªq kw³‡K wb‡Ri ÁvZmv‡i ev AÁvZmv‡i †Kv‡bviKg Ace¨envi
K‡i wb‡R ¶wZMÖ¯Í n‡j ev A‡b¨i ¶wZ Ki‡j ev †Kv‡bv AvBb j•Nb Ki‡j Zvi cy‡iv AvBbMZ `vwqZ¡ Avgvi wb‡Ri Ici eZ©v‡e|
GR‡b¨ gnvRvZK, †Kvqv›Uvg †g_W ev †hvM dvD‡Ûkb †Kv‡bvfv‡eB `vqx _vK‡e bv|

¯^v¶i/ Signature

C
OFFICE USE ONLY CENTER/ BRANCH/ CELL ENTRY E

REG. NO. DATE ORGANIER SCAN