mgvR‡mev Awa`dZi

mgvRKj¨vY gš¿Yvjq
MYcÖRvZš¿x evsjv‡`k miKvi

eq¯‹ fvZv gÄyixi Av‡e`bcÎ

cÖ_g Ask

(Av‡e`bKvix wb‡R c~iY I ¯^v¶i Kwi‡eb A_ev Kvnv‡iv Øviv c~iY Kwiqv wb‡R ¯^v¶i/wUcmwn w`‡eb)

eivei
.............................................
............................................. cvm‡cvU© mvB‡Ri
........................................... mZ¨vwqZ Qwe

welqt eq¯‹ fvZv gÄyixi Rb¨ Av‡e`b|

g‡nv`q,

webxZ wb‡e`b GB †h, Avgvi eZ©gvb eqm ................ ermi| Avwg MYcÖRvZš¿x evsjv‡`k miKvi
KZ…©K †NvwlZ gvwmK ............................ UvKv nv‡i eq¯‹ fvZv cÖvwßi Rb¨ Av‡e`b RvbvB‡ZwQ Ges GB
m~‡Î wbgœwjwLZ Z_¨vw` Avcbvi mnvbyf~wZkxj we‡ePbvi Rb¨ †ck Kwi‡ZwQ t-

(K) bvg t
(L) wcZv/¯^vgxi bvg t
(M) gvZvi bvg t
(N) wVKvbv t
eZ©gvb t ..........................................
..........................................
..........................................
..........................................

¯’vqx t .........................................
.........................................
.........................................
.........................................

(K) Av‡e`bKvixi evrmwiK Mo Avq t

(P) ¯^v¯’¨MZ Ae¯’v t

(cÖ‡hvR¨ †¶‡Î √ wPý w`b) (1) m¤ú~Y© (2) Amy¯’ (3) AcÖK…wZ¯’ (4) cÖwZeÜx (5) AvswkK
Kg©¶gZvnxb Kg©¶gZvnxb

(Q) Av_©-mvgvwRK Ae¯’v t Q.1.

(cÖ‡hvR¨ †¶‡Î √ wPý w`b) (1) wbt¯^ (2) DØv¯‘ (3) f~wgnxb

Q.2.

1) weaev (2) ZvjvKcÖvß (3) wecZœxK (4) cwievi †_‡K

wew”Qbœ

BB-vata 1
 -2-

(R) Rb¥ ZvwiL/AvbygvwbK Rb¥ ZvwiL t

(S) mbv³KiY wPý t

(T) gyw³‡hv×v wKbv t

(U) mbv³Kvix t

...................................................................
(IqvW© m`m¨/m`m¨v/BDwbqb cwil` †Pqvig¨vb)

2| Avgvi kvixwiK A¶gZvRwbZ Kvi‡Y eq¯‹fvZv MÖn‡Yi Rb¨ mkix‡i Dcw¯’Z nIqv m¤¢e bq| ZvB
Avgvi eq¯‹ fvZv MÖn‡Yi Rb¨ wbgœewY©Z e¨w³‡K g‡bvbqb `vb Kwijvgt-

bvg I wVKvbv m¤úK© g‡bvbxZ e¨w³i bgybv eq¯‹ fvZv‡fvMxi

¯^v¶i cÖwZ¯^v¶i/wUcmwn

Avcbvi AbyMZ
ZvwiLt
Av‡e`bKvixi ¯^v¶i t

Av‡e`bKvixi bvg t

bgybv ¯^v¶i/wUcmwn t

wØZxq Ask
gÄyiKvix KZ…©c‡¶i Av‡`k

.................................................................. †K gvwmK
........................................................... UvKv nv‡i eq¯‹fvZv gÄyi Kiv nBj|

Dc-cwiPvjK/mgvR‡mev Kg©KZv©i
¯^v¶i
ZvwiL t

(mxj‡gvni)

wet `ªt eq¯‹fvZv gÄyi Kivi ci Av‡e`b c‡Îi cÖ_g As‡ki Qwei Dci mgvR‡mev Kvh©vj‡qi †Mvj mxj‡gvni w`‡Z
n‡e|

BB-vata 2
 eq¯‹ fvZv cwi‡kv‡ai Av‡`k
[e¨qbKvixi (e¨vsK) Ask]
cvm‡cvU© mvB‡Ri
mZ¨vwqZ Qwe|

.....................................
cÖ_g A_© cwi‡kv‡ai mgq eq¯‹fvZv
MÖnYKvixi ¯^v¶i/wUcmwn

eq¯‹ fvZvi kvixwiK R‡b¥i mwVK m¤cÖ`vq fvZv MÖnYKvixi wVKvbv gvwmK
gÄyix mbv³Ki‡Yi ZvwiL A_ev fvZvi
Av‡`kbvgvi wPý AvbygvwbK cwigvY
ZvwiL ZvwiL

†Rjv/Dc‡Rjv wnmvei¶Y Kg©KZ©vi Kvh©vjq

..............................................

bs ZvwiLt ......................
Rbve,
GB Av‡`kbvgvq eq¯‹ fvZv MÖnYKvixi Ask Dc¯’vc‡b Ges cÖPwjZ aviv †gvZv‡eK `vex`v‡ii wbKU nB‡Z
A_© cÖvwßi iwk` MÖnYmv‡c‡¶ cieZx© Av‡`k bv cvIqv ch©š— cÖwZ gvm AwZμvš— nB‡j Rbve/†eMg
.........................................................wcZv/¯^vgxi bvg ......................................................................
gvZvi bvg .................................................. MÖvg/gnj v/iv¯—
v..............................................................., IqvW© bs
.................................BDwbqb/†cŠimfv/wmwU K‡c©v‡ikb ........................................................
Dc‡Rjv/_vbv.................................................... †Rjv ................................................... †K eq¯‹ fvZv
eve`........................................... UvKv cÖ`v‡bi Aby‡iva Kiv hvB‡Z‡Q| ...................................... wLªt
nB‡Z A_© cÖ`vb Kwi‡Z nB‡e|

`¯—LZ t
.....................................
c`ex t.......................................

(mxj‡gvni)

g¨v‡bRvi
................................................. e¨vsK
................................................. kvLv

Dc‡Rjv/_vbv t ...................................
‡Rjv t.........................................

wet `ªt cvm‡cvU© mvB‡Ri mZ¨vwqZ Qwei Dci †Rjv/Dc‡Rjv wnmve i¶Y Kvh©vj‡qi †Mvj mxj‡gvni w`‡Z nB‡e|

BB-vata 3
 e¨qbKvixi As‡ki wecixZ c„ôv

eq¯‹fvZvi cwigvY t UvKv.......................... (K_vq) .......................................................................UvKv

....................................................... ZvwiL nB‡Z cÖ‡`q|

A_© cwi‡kv‡ai weeiY

gv‡mi bvg (†h mKj gv‡mi eq¯‹fvZvi A_© cÖ‡`q UvKvi cwigvY e¨qb Awdmv‡ii gšÍe¨
fvZv cwi‡kva nB‡e) cwi‡kv‡ai ZvwiL ¯^v¶i

BB-vata 4
 ewn b¤^i ..................

g‡bvMÖvg

eq¯‹ fvZv cwi‡kva ewn

[eq¯‹fvZv MÖnYKvixi Ask]

mgvR‡mev Awa`dZi
mgvRKj¨vY gš¿Yvjq

BB-vata 5
 cvm‡cvU© mvB‡Ri
mZ¨vwqZ Qwe|
Qwei Dci mgvR‡mev
Kvh©vj‡qi †Mvj
mxj‡gvni w`‡Z nB‡e|

1| LiP enbKvix t................................................................

2| wnmv‡ei LvZ/†KvW t.................................................................

3| gyL¨ LvZ t.................................................................

4| ‡MŠYLvZ t.................................................................

5| eq¯‹ fvZv MÖnxZvi bvg t.................................................................

6| wcZv/¯^vgxi bvg t ................................................................

7| gvZvi bvg t ................................................................

8| wVKvbvt K. ¯’vqx t
.................................................
..................................................
.................................................
................................................
L. eZ©gvb t
...............................................
...............................................
...............................................
...............................................

9| Rb¥ ZvwiL A_ev AvbygvwbK Rb¥ ZvwiL t

10| eq¯‹ fvZv‡fvMxi kvixwiK mbv³Ki‡Yi wPý (hw` _v‡K) t

Dc cwiPvjK/mgvR‡mev Kg©KZ©vi m¦v¶i

ZvwiL t ÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐÐ
(mxj †gvni)

BB-vata 6
 -2-

eq¯‹fvZv cwi‡kv‡ai Av‡`k

.................................... Awdm

bs ZvwiLt .........................

Rbve,

Ab¨ †Kvb Av‡`k bv cvIqv ch©š— cÖ‡Z¨K gvm †kl nB‡j AbyMÖnc~e©K
....................................... †K eq¯‹ fvZv eve` ....................................UvKv G Av‡`kbvgv
Dc¯’vcb I wbqwgZ dig Abymv‡i iwk` `vwL‡ji ci cwi‡kva Kiv nDK|

¯^v¶i .....................................
c`ex ....................................

eivei,
...............................................
...............................................

UxKvt 1| GB Av‡`‡ki Aaxb †Kej mkix‡i Dcw¯’Z eq¯‹ fvZv‡fvMx‡KB A_© cwi‡kva Kwi‡Z nB‡e|

2| c`©vbkxj gwnjv Ges Amy¯’Zv I kvixwiK Kvi‡Y Dcw¯’Z nB‡Z Amg_© eq¯‹ fvZv‡fvMx
Zuvnvi c‡¶ fvZvMÖn‡Yi Rb¨ Ab¨ †Kvb e¨w³‡K wjwLZfv‡e g‡bvbqb cÖ`vb Kwi‡eb Ges
g‡bvbxZ e¨w³ fvZv MÖn‡Yi mgq cÖwZevi mswk ó eq¯‹ e¨w³ RxweZ Av‡Qb GB g‡g© ¯’vbxq
cÖwZwbwa (IqvW© Kwgkbvi/IqvW© †g¤^vi/BDwbqb cwil` †Pqvig¨vb) Gi mb`cÎ †ck Kwi‡eb
;

3| fvZv‡fvMxi g„Zz¨i ci Zuvi bwgbx/g‡bvbxZ e¨w³ e‡Kqv fvZvmn cieZx© 03 (wZb) gv‡mi
fvZv cÖvc¨ nIqvi ci A_ev bwgbx bv _vK‡j fvZv‡fvMxi g„Zz¨i c‡ii gvm nB‡Z GB
Av‡`kbvgv evwZj ewjqv MY¨ nB‡e|
[[[

BB-vata 7
 -4-
1| eq¯‹ fvZvi cwigvY t UvKv ....................... (K_vq) ...................................................UvKv
2| cÖ‡Z¨K ev‡ii †`q UvKv wjwce× Kwi‡Z nB‡e t

gv‡mi bvg (†h mKj gvwmK cÖ‡`q UvKvi UvKv †`Iqvi fvZv MÖnxZvi fvZv
gv‡mi fvZv cwi‡kva fvZvi nvi cwigvb ZvwiL ¯^v¶i/wUcmwn cwi‡kvaKvixi
Kwi‡Z nB‡e) ¯^v¶i

BB-vata 8
 Am”Qj cÖwZeÜx fvZv gÄyixi Av‡e`bcÎ

(Av‡e`bKvix wb‡R c~iY I ¯^v¶i Ki‡eb A_ev Kv‡iv Øviv c~iY K‡i wb‡R ¯^v¶i/wUcmwn w`‡eb)

eivei, cvm‡cvU© mvB‡Ri

............................................... mZ¨vwqZ Qwe|
.............................................
welqt Am”Qj cÖwZeÜx e¨w³‡`i fvZv gÄyixi Rb¨ Av‡e`b|
g‡nv`q,
webxZ wb‡e`b GB †h, Avwg GKRb ............................... cÖwZeÜx e¨w³| Avgvi eqm ..........
eQi| Avwg miKvi KZ…©K cÖ`Ë Am”Qj cÖwZeÜx e¨w³‡`i Rb¨ eivÏK…Z fvZv cÖvwßi Av‡e`b KiwQ| Avgvi
Z_¨vw` wb‡gœ cÖ`Ë nj | D‡j L¨ †h, Avgvi wb‡gœ ewY©Z Z_¨vw` mZ¨ |

1. bvgt ........................................................................................................
2. wcZv/¯^vgxi bvg t ........................................3. gvZvi bvgt ........................................
4.K. eZ©gvb wVKvbv t L. ¯’vqx wVKvbv t
...........................................
..............................................
............................................
..............................................
............................................ .............................................
5. evwl©K Mo Avq t ...............................................................................................
6. ¯^v¯’¨MZ Ae¯’v t K. PjvP‡j m¶g L. PjvP‡j A¶g
7. cÖwZeÜx‡Z¡i aiY t ....................................................................................
8. Av_©-mvgvwRK Ae¯’v t K. RwgRgvi cwigvb ............................................
L. weevwnZ/AweevwnZ .........................................
[

M. ‡Q‡j-‡g‡qi msL¨v ...........................................

mbv³Kvixi bvg I ¯^v¶i(mxjmn) Av‡e`bKvixi ¯^v¶i/wUcmwn

9. mycvwik t Av‡e`bKvixi eY©bv mZ¨| wZwb fvZv cÖvwßi †hvM¨/A‡hvM¨| Zv‡K fvZv cÖ`vb Kiv †h‡Z
[
cv‡i/cv‡ibv|

BDwc m`m¨/†Pqvig¨vb/†cŠimfv/wmwU
K‡c©v‡ik‡bi Kwgkbv‡ii ¯^v¶i t

gÄyiKvix KZ©„c‡¶i ¯^v¶it

mgvR‡mev Kg©KZ©v(bv‡gi mxjmn)

BB-vata 9
 -11-
[

fvZv cwi‡kva eB
eB b¤^i ..................

[fvZv MÖnYKvixi Ask]

cvm‡cvU© mvB‡Ri
mZ¨vwqZ Qwe|

1| fvZv MÖnxZvi bvg t.................................................................

2| wcZv/¯^vgxi bvg t ................................................................

3| gvZvi bvg t ................................................................

4| K. eZ©gvb wVKvbv t ...................................................................

..................................................................
..................................................................
.................................................................

L. ¯’vqx wVKvbv t .................................................................

..................................................................
.................................................................
............................................................

5| cÖwZeÜx‡Z¡i aiY t

6| LiP enbKvix t MYcÖRvZš¿x evsjv‡`k miKvi

7| wnmv‡ei LvZ/†KvW t 2905

8| gyL¨ LvZ t 5900

9| ‡MŠYLvZ t 5925

10| mgvR‡mev Kg©KZ©vi ¯^v¶i(bv‡gi mxjmn) t

BB-vata 10
 -12-

fvZv cwi‡kv‡ai Av‡`k bvgv

wnmve i¶Y Kg©KZ©vi Kvh©vjq

bs ZvwiLt .........................

cÖvcK,
e¨ve¯’vcK
..........................................e¨vsK
............................................kvLv
Dc‡Rjv t..............................
‡Rjv t................................

Rbve,
cybiv‡`k bv †`Iqv ch©š— ................................................................ †K cÖ‡Z¨K gvm †kl n‡j
D³ gv‡mi fvZv eve` ................................................. UvKv G Av‡`kbvgv Dc¯’vcb I cÖ‡qvRbxq
AvbyôvwbKZv m¤úbœ Kivi ci wbgœewY©Z kZ© mv‡c‡¶ cÖ`v‡bi Rb¨ Aby‡iva Kiv n‡jv|

¯^v¶i
.....................................
bvg........................................
.
c`ex ....................................
(bv‡gi mxjmn)

UxKvt 1| mkix‡i Dcw¯’Z fvZv‡fvMx‡K fvZv cÖ`vb Ki‡Z n‡e ;

2| Abycw¯’Z fvZv‡fvMxi cÖwZwbwa‡K Dchy³ cÖZ¨qbcÎ mv‡c‡¶ fvZv cÖ`vb Kiv hv‡e ;
3| ‡Kvb fvZv‡fvMxi g„Zz¨ n‡j G Av‡`kbvgv evwZj e‡j MY¨ n‡e|
[[[

BB-vata 11
 -13-

1| cÖwZeÜx e¨w³‡`i fvZvi cwigvY t ...................................K_vq ...............................UvKv

2| fvZv cÖ`v‡bi ÒQKÓ (cÖ‡Z¨K ev‡ii UvKv wjwce× Ki‡Z n‡e) t

gv‡mi bvg (†h mKj gvwmK cÖ‡`q UvKvi UvKv †`Iqvi fvZv MÖnxZvi fvZv
gv‡mi fvZv cwi‡kva fvZvi nvi cwigvb ZvwiL ¯^v¶i/wUcmwn cwi‡kvaKvixi
Ki‡Z n‡e) ¯^v¶i

BB-vata 12
 -14-
fvZv cwi‡kv‡ai Av‡`kbvgv (wW-nvd)
Am”Qj cÖwZeÜx e¨w³‡`i fvZv cwi‡kv‡ai Av‡`kbvgv
[cwi‡kvaKvix e¨vs‡Ki Ask]

cvm‡cvU©
mvB‡Ri
mZ¨vwqZ Qwe|
.....................................
cÖ_g A_© cwi‡kv‡ai mgq fvZv
MÖnYKvixi ¯^v¶i/wUcmwn
fvZv gÄyix Av‡`‡ki kvixwiK mbv³KiY wPý R¤§ ZvwiL/eqm fvZv MÖnYKvixi wVKvbv gvwmK fvZvi
ZvwiL cwigvY

wnmve i¶Y Kg©KZ©vi Av‡`kbvgv

†Rjv/Dc‡Rjv wnmvei¶Y Kg©KZ©vi Kvh©vjq
..............................................
bs ZvwiLt
..............................
e¨e¯’vcK,
................................................. e¨vsK
................................................. kvLv
Dc‡Rjv t ...................................
‡Rjv t.........................................

g‡nv`q,
ewY©Z Av‡`kbvgvq fvZv‡fvMxi Ask Dc¯’vcb mv‡c‡¶ cÖPwjZ aviv †gvZv‡eK `vex`v‡ii wbKU n‡Z A_© cÖvwßi iwk`
MÖnYc~e©K cieZx© Av‡`k bv cvIqv ch©š— cÖwZ gvm AwZμvš— n‡j
Rbve/†eMg....................................................................
wcZv/¯^vgx.............................................................................,gvZv................................................................
.....
MÖvg/gnj v/iv¯—v.........................................................., BDwbqb/†cŠimfv/IqvW© bs (wmwUK‡c©v‡ikb)
............................ Dc‡Rjv/_vbv..................................................†Rjv
.......................................................................... †K cÖwZeÜx fvZv eve` ..................................................UvKv
cÖ`v‡bi Aby‡iva Kiv hv‡”Q| ................... n‡Z ................... ch©š— A_© cÖ`vb Ki‡Z n‡e|

¯^v¶it .....................................
bvgt..............................................
c`ext.......................................
(bv‡gi mxjmn)

BB-vata 13
 -15-
e¨qbKvixi As‡ki wecixZ c„ôv
cÖwZeÜx fvZvi cwigvY .................................... (K_vq
.................................................................................................UvKv)
................................................................... ZvwiL n‡Z cÖ‡`q|

cÖwZwU ¯^Zš¿ A_© cwi‡kv‡ai weeiY

gv‡mi bvg (†h mKj cÖwZeÜx fvZvi A_© cÖ‡`q UvKvi e¨qb Awdmv‡ii e¨vsK e¨e¯’vc‡Ki gš—e¨
gv‡mi fvZv cwi‡kva cwi‡kv‡ai ZvwiL ¯^v¶i ¯^v¶i
nq)
cwigvb

BB-vata 14