eivei

e¨e¯ ’vcbv cwiPvjK

XvKv Iqvmv|

Av‡e`bK„Z c‡`i bvg t ...................................................................

b¨vkbvj AvBwW bs t ................................................................

Av‡e`bKvixi bvg (Bs‡iRx eo nv‡Zi A¶i) t ..........................................................................................

Av‡e`bKvixi bvg (evsjvq) t ..........................................................................................

wcZvi bvg t ................................................ ¯^vgx / ¿xi bvg t ......................................................

gvZvi bvg t ............................................... ......................................................

eZ©gvb wVKvbv t................................................ ¯ ’vqx wVKvbv t ‡Rjv t ......................................

t ...............................................

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(weevwnZv gwnjvi

†¶‡Î ¯vgxi ¯ ’vqx

wVKvbv)

Dc‡Rjv t ......................................

WvKNi t ......................................

Mªvg/moK t ......................................

†gvevBj / †Uwj‡dvb t .............................................. e-mail address :........................................................

RvZxqZv t ...............................................

Rb¥ ZvwiL t ...............................................

31/01/13 Zvwi‡L eqm gvm w`b

ag© t ...............................................

‡c-AW©vi/e¨vsK WªvdU Gi Z_¨ t

b¤i I ZvwiL t ............................................................

A‡_©i cwigvY t ............................................................

e¨vsK t ...........................................................

wk¶vMZ ‡hvM¨Zv t

wWMªx Mª“c/welq ‡evW©/wek¦we`¨vjq wk¶v cªwZôv‡bi bvg cv‡mi ermi wefvM/wRwcG

PvKyixi AwfÁZv t

PvKyixiKvj c‡`i bvg ‡eZbµg/‡MªW

ZvwiL nB‡Z ZvwiL ch©š— cªwZôv‡bi bvg

wet ªt cª‡qvR‡b AwZwi³ cvZv e¨envi Kiv hv‡e|

cª‡hvR¨ †¶‡Î √ wPý w`b gyw³‡hv×vi mš—vb wefvMxq cªv_x© cªwZeÜx DcRvZxq gwnjv

Av‡e`bKvixi ¯^v¶i I ZvwiL

cvm‡cvU© mvB‡Ri

03wU mZ¨vwqZ Qwe