WvP&-evsjv e¨vsK dvD‡Ûk‡bi e„wËi Rb¨ Av‡e`bcÎ

Awd‡mi e¨env‡ii Rb¨

‡KvW bs:

Av‡e`bKvixi m`¨ †Zvjv 1 wbix¶‡Ki ¯^v¶i:

Kwc Qwe GLv‡b AvVv w`‡q
jvMv‡Z n‡e| P~ovšÍ djvdj:

(Av‡e`bKvix‡K Aek¨B wbR nv‡Z Av‡e`bcÎ c~iY Ki‡Z n‡e)

1| Av‡e`bKvixi bvg (evsjvq) :

(mvwU©wd‡KU Abyhvqx)
(Bs‡iRx‡Z) :

2| wcZvi bvg :

3| wcZvi wk¶vMZ †hvM¨Zv :

4| gvZvi bvg :

5| gvZvi wk¶vMZ †hvM¨Zv :

6| Rb¥ ZvwiL :

7| eZ©gvb wVKvbv :

8| ¯’vqx wVKvbv MÖvg : WvKNi:

_vbv/ Dc‡Rjv : †Rjv:

9| Riæix †hvMv‡hv‡Mi Rb¨ †dvb bs : †gvevBj bs:

10| weMZ †evW©/wk¶v cÖwZôv‡bi cix¶v mg~‡ni weeiY :
mswkøó cix¶vi cÖvß wRwcG
cix¶vi bvg cv‡ki mb wk¶v cÖwZôv‡bi bvg wk¶v †evW©
‡ivj bs ‡gvU 4_© welq ev‡`

Gm Gm wm

GBP Gm wm

11| cÖv_wgK/Rywbqi e„wË cÖvß n‡j Zvi weeiY :

(mswk¬ó mb`c‡Îi d‡UvKwc mZ¨vwqZ K‡i mshy³
e„wËi ch©vq e„wË cÖvwßi mb cÖvß djvdj
(U¨v‡j›Ucyj/ mvaviY)
Ki‡Z n‡e)
cÖv_wgK e„wË
Rywbqi e„wË
12| Av‡e`bKvixi eZ©gvb wk¶v¯Í‡ii weeiY:
cÖwZôv‡bi bvg:----------------------------------------------------------------------------------------------------------------
‡mkb------------------------- wefvM/welq ------------------------------------------------- µwgK bs------------------------
 (2)
13| Av‡e`bKvixi cwiev‡ii DcvR©b m¤úwK©Z weeiY:
DcvR©bkxj e¨w³ ‡ckvi c~Y© bvg I c`ex Kg©iZ cÖwZôv‡bi bvg I wVKvbv ‡dvb bs evrmwiK DcvR©b
K) wcZv/ ‰ea AwffveK
L) wcZv AemicÖvß n‡j
c~e©eZx© †ckvi weeiY
M) gvZv
N) cwiev‡ii Ab¨vb¨
m`m¨‡`i Avq (†hgb-
fvB, †evb BZ¨vw`)
O) wcZv / gvZv g„Z n‡j ‡ckvMZ c`ex (wcZv): cÖwZôv‡bi bvg:
c~e©eZx© †ckvi weeiY
‡ckvMZ c`ex (gvZv): cÖwZôv‡bi bvg:

14| cwiev‡ii Ab¨vb¨ DcvR©b:

K) e¨emv:
e¨emv cÖwZôv‡bi bvg I wVKvbv:
e¨emvi aiY/we¯ÍvwiZ weeiY :
e¨emv cÖwZôvb cwiPvjbvq gvwmK e¨q (†hgb-‡`vKvb
fvov, Kg©Pvix‡`i †eZb, we`y¨r wej, †Uwj‡dvb wej BZ¨vw`):
evrmwiK DcvR©b:

L) K…wl KvR:
Kv‡Ri aiY (wUK wPý w`b): wb‡Ri Rwg wb‡RB Pvl Kiv nq/ wb‡Ri Rwg eM©v w`‡q Pvl Kiv‡bv nq/ A‡b¨i Rwg eM©v wb‡q Pvl Kiv nq/
wb‡Ri I A‡b¨i Rwg eM©v wb‡q Pvl Kiv nq/ Ab¨vb¨..................................................................................
K…wl Rwgi cwigvY: kZvsk evrmwiK DcvR©b:

M) grm¨ Pvl:
Pv‡li aiY (wUK wPý w`b): wb‡Ri cyKzi ev †Ni/ A‡b¨i cyKzi ev †Ni wjR wb‡q grm¨ Pvl/ Ab¨vb¨.........................................

cyKzi ev †N‡ii msL¨v: cyKzi ev †N‡ii Rwgi cwigvY: kZvsk evrmwiK DcvR©b:

N) Mevw` cï cvjb :
Mevw` cïi weeiY: msL¨v: evrmwiK DcvR©b:

O) fvov:
Ni/ evwoi aiY: wUb‡kW Kv‡Vi Ni/wUb‡kW wewìs/ cvKv wewìs msL¨v: evrmwiK DcvR©b:
†`vKv‡bi aiY: msL¨v: evrmwiK DcvR©b:
Mvwo/ hvbevn‡bi aiY: msL¨v: evrmwiK DcvR©b:

P) †cbkb/ Ab¨vb¨ fvZv:

AemiKvjxb mg‡q †ckvi c`ex : evrmwiK DcvR©b:

Q) we‡`k †_‡K:
†`‡ki bvg: we‡`‡k Ae¯’vbKvj: eQi evrmwiK DcvR©b:

R) Ab¨vb¨ Drm:
15| cwiev‡ii †gvU evrmwiK Avq/ DcvR©b (UvKv):
(we.`ª. cÖ`Ë Z_¨ wg_¨v ev mvRv‡bv ev fyj cÖgvwYZ n‡j wKsev †Kvb Z_¨ †Mvcb Ki‡j Av‡e`bcÎ mivmwi evwZj e‡j MY¨ n‡e|)
 (3)

Av‡e`bKvixi wcZvi m`¨ †Zvjv Av‡e`bKvixi gvZvi m`¨ †Zvjv Av‡e`bKvixi m`¨ †Zvjv 2 Kwc
1 Kwc Qwe (Av‡e`bKvix KZ…©K 1 Kwc Qwe (Av‡e`bKvix KZ…©K mZ¨vwqZ Qwe GKmv‡_ ÷¨vcj
mZ¨vwqZ) GLv‡b ÷¨vcj K‡i mZ¨vwqZ) GLv‡b ÷¨vcj K‡i K‡i GLv‡b jvMv‡Z n‡e|
jvMv‡Z n‡e| jvMv‡Z n‡e|

16| emZ evwoi weeiY:

emZ evwoi aiY: (wUK wPý w`b) wUb‡kW Kv‡Vi Ni/ wUb‡kW wewìs/ cvKv wewìs/ Ab¨vb¨.......................................................|

emZ evwoi Ae¯’vb: knivÂj / MªvgvÂj (wUK wPý w`b) emZ evwoi cwigvY : kZvsk

17| cwiev‡ii weeiY:

cwiev‡ii †gvU m`m¨ msL¨v: cwiev‡ii Dc©vRbkxj m`m¨ msL¨v:

18| Av‡e`bKvixi Aa¨qYiZ Ab¨vb¨ fvB/ †ev‡bi weeiY:

µwgK bs fvB/ †ev‡bi bvg ‡kªYx Aa¨qYiZ wk¶v cÖwZôv‡bi bvg

19| Av‡e`bKvixi fvB/ †evb †KD WvP&-evsjv e¨vsK n‡Z e„wË cÖvß n‡j Zvi weeiY:
fvB/ †ev‡bi bvg e„wËi e¨vP I wmwiqvj bs wk¶v¯Íi

20| Av‡e`bKvix c~‡e© WvP&-evsjv e¨vsK n‡Z e„wË cÖvß n‡j, e„wËi wmwiqvj bs :.................., Gm.Gm.wm........................... e¨vP|

21| Avwg cÖwZÁvc~e©K ejwQ †h, Dc‡i D‡jøwLZ weeiYvw` Avgvi Ávb I wek¦vm g‡Z mZ¨ Ges †KvbI welq AmZ¨ cÖgvwYZ n‡j Avgvi
e„wË evwZj e‡j MY¨ n‡e Ges M„nxZ e„wËi UvKv †dir w`‡Z eva¨ _vKe|

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

wcZvi ¯^v¶i gvZvi ¯^v¶i Av‡e`bKvixi ¯^v¶i
ZvwiL: ZvwiL: ZvwiL:

22| c~e©eZ©x /eZ©gvb wk¶v cÖwZôv‡bi cÖav‡bi gšÍe¨:

.......................................
¯^v¶i Ges bvgmn mxj‡gvni
ZvwiL:
 (4)

Av‡e`bc‡Îi mv‡_ †Kej c~e©eZ©x / eZ©gvb wk¶v cÖwZôv‡bi cÖavb / wefvMxq cÖavb KZ©„K mZ¨vwqZ wbgœwjwLZ ms‡hvRbxmg~n `vwLj
Ki‡Z n‡e :

1| Av‡e`bKvix I Zvi wcZv-gvZvi m`¨ ‡Zvjv Qwe h_v¯’v‡b mwVKfv‡e mshy³ Ki‡Z n‡e |

2| Gm. Gm. wm./ GBP .Gm. wm. cv‡ki mvwU©wd‡K‡Ui (hw` _v‡K) d‡UvKwc (mZ¨vwqZ)|

3| Gm. Gm. wm./ GBP. Gm. wm. cv‡ki UªvÝwµÞ / gvK©wm‡Ui d‡UvKwc (mZ¨vwqZ)|

4| Gm. Gm. wm/ GBP. Gm. wm cv‡ki cÖksmvcÎ/ †Uwó‡gvwbqvj Gi d‡UvKwc (mZ¨vwqZ)|

5| Gm. Gm. wm./ GBP. Gm. wm. cix¶vi †iwR‡÷ªkb KvW© I cÖ‡ekc‡Îi d‡UvKwc (mZ¨vwqZ)|

6| wcZv I gvZvi Qwe hy³ RvZxq cwiPqc‡Îi d‡UvKwc|

7| ** wbgœwjwLZ `yBwU Drm †_‡K cÖZ¨vwqZ wcZv I gvZv/ Awffve‡Ki Av‡qi weei‡Yi g~j Kwc (Av‡qi weeiYx‡Z Aek¨B wcZv I
gvZv/ Awffve‡Ki †ckv D‡j¬L _vK‡Z n‡e):

* K) me©‡kl cvkK…Z wk¶v cÖwZôv‡bi cÖavb |

* L) PvKzixiZ wcZv/ gvZv/ AwffveK‡`i †¶‡Î mswk¬ó cÖwZôv‡bi D”Pc`¯’ Kg©KZ©v/ Ab¨vb¨ †¶‡Î 1g †kªYxi miKvix Kg©KZ©v /
mswk¬ó IqvW© Kwgkbvi A_ev BDwc †Pqvig¨vb |

we‡kl `ªóe¨:
▪ we‡kl Z‡_¨i Rb¨ Avjv`v KvMR mshy³ Kiv hv‡e|
▪ Am¤ú~Y© Av‡e`bcÎ evwZj e‡j MY¨ n‡e|
▪ e„wË cÖ`v‡bi wel‡q KZ©„c‡¶i wm×všÍB P~ovšÍ e‡j we‡ewPZ n‡e|

™ mwVKfv‡e c~iYK…Z Av‡e`bcÎ I cÖ‡qvRbxq KvMRcÎvw` GKmv‡_ ÷¨vcj K‡i wb‡gœv³ wVKvbvq WvK / Kzwiqvi ‡hv‡M
A_ev mivmwi cvVv‡Z n‡e :

WvP&-evsjv e¨vsK dvD‡Ûkb,

47, gwZwSj ev/G
XvKv-1000|