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(9) (2) gFÂia fh©f
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bjhêyhëæ‹ bga® _________________________ Kftç ____________________

jªij / fzt® _________________________ ____________________
Ãwªj nj taJ _________________________ ____________________
bjhêè‹ j‹ik _________________________ ____________________
gâ brŒÍ« fhy« _________________________ bjhiyngÁ v©: _______________

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ÂU / ÂUk / bršé ________________________________ M»a eh‹ jäHf murhš

mik¡f¥g£LŸs clYiH¥ò eythça« mšyJ ntW eythça§fëš cW¥Ãduhfnth / ntW muR
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ÂU / ÂUk / bršé ___________________________ v‹gt® ________________________________

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k‰W« K¤Âiu
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