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¨Šº°É .......................œ...µ..¥...‡............................ Ÿ¼…o °¦´Ä®o
¨ŠÉº° ........................................................... Ÿo­¼ °­ªœ

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­Îµ®¦´ ¡œ„´ ŠµœÁ‹µo ®œµo šÉ¸

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‹µÎ œªœšÉ—¸ œ· ....................….........………......….......Ŧn...............……......……………....................Šµœ...............……....…........…...........˜µ¦µŠªµ
‡ŠÁ®¨º°.........................................………......….....Ŧn.............……..........……………..............….Šµœ.........…….........…..…..................˜µ¦µŠªµ
Ô) ŗ‹o —š³Á¥¸ œÂ¨ªo ˜ªn ´œš.ɸ ..............…...............Á—°º œ...............................¡.«. ……………….

¨ŠÉº° ....................................................................
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Á‹oµ¡œ´„Šµœš—¸É œ·

˜´ª°¥nµŠš¸É Ó (š.—. ÒÕ …)

®œ´Š­°º ­´ µÄ®šo ɸ—·œÁŒ¡µ³­nªœ

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˜ª´ °¥nµŠšÉ¸ Ô † š¸É µo œ (š.—. Ò)

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Á¨…š¸É—œ· ..................................................................………............…°ÎµÁ£°.....................................…...........................................……....................…..

®œoµ­µÎ ¦ª‹...................................................................……..............‹´Š®ª´—...........................................................................................……........…….
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¨ŠºÉ° ........................................................... Ÿo¼­°­ªœ

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­Îµ®¦´ ¡œ„´ ŠµœÁ‹oµ®œoµš¸É

Ò) ¦µ‡µž¦³Á¤œ· šœ» š¦´¡¥.r .......................................………........……………...................………….µš..........…….…….............…..............­˜µŠ‡r
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‹Îµœªœš—¸É ·œ....................….........………......….......Ŧn...............……......……………....................Šµœ...............……....…........…...........˜µ¦µŠªµ
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Ô) ŗ‹o —š³Á¥¸ œÂ¨ªo ˜nª´œš.ɸ ..............…...............Á—°º œ...............................¡.«. ……………….

¨Š°ºÉ ....................................................................
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Á‹oµ¡œ´„Šµœš—¸É œ·

˜´ª°¥nµŠš¸É Ô

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šÉ¸—·œ ®œŠ´ ­º°­´ µÄ®šo ¸É—·œ (¦³®ªnµŠ‹Îµœ°Š)

̜—š.¸É ......……………………...….Á¨…šÉ—¸ œ· ...............……….……..®œµo ­Îµ¦ª‹...........…………………….

˜Îµ¨.......…………..……..…......….°µÎ Á£°..........…..…….…….…...‹´Š®ª´—..........…...........................….....

®œ´Š­°º ­´ µœ¸ÅÊ —ošµÎ Á¤ºÉ°ªœ´ š…ɸ …………………Á—º°œ…………...…………………¡»š›«´„¦µ…………….……

– ­µÎ œ„´ ŠµœšÉ¸—·œ‹´Š®ª´—……………..…………………… Á¨…ž¦³‹Îµ˜ª´ ž¦³µœ

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šÊ´Š­°Š iµ¥Å—o˜„¨ŠšµÎ ­´ µ„œ´ —Š´ ˜n°Åžœ¸Ê
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(¨Š¨µ¥¤°º ºÉ°¡¥µœ)…………………………………………..
(¨Š¨µ¥¤°º Éº°¡¥µœ)…………………………………………..
®œŠ´ ­°º ­´ µœ¸ÅÊ —ošµÎ ˜n°®œoµ
………………………………………….………..Á‹µo ¡œ´„Šµœš—ɸ œ·
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Á¨…š—ɸ ·œ ¨Š¨µ¥¤º°Éº°
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Ŧn Šµœ ˜µ¦µŠ Ŧn Šµœ ˜µ¦µŠ
ªµ ªµ

ªœ´ šÉ¸…………. Ä®o Ò. œµ¥ „. Ò- - --- - (¨ŠÉ°º )……………
Ó. œµŠ ….
Á—º°œ………… (¦³®ªnµŠ‹Îµœ°Š)
¡.«. …………

˜´ª°¥nµŠšÉ¸ Õ † š¸Éµo œ (š.—. Ò)

† š­É¸ ªœ/Ŧn
† š¸œÉ µ
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˜µÎ ®œnŠšÉ¸—œ· (¦³®ªnµŠ‹µÎ œ°Š) † ĜÁ…˜

¦³ªµŠ..........................................…..........................................……..˜µÎ ¨.........................................……......….....................................................…..

Á¨…šÉ¸—œ· ..................................................................………............…°ÎµÁ£°.....................................…...........................................……....................…..

®œµo ­Îµ¦ª‹...................................................................……..............‹´Š®ª´—...........................................................................................……........…….
̜—š—¸É ·œ
Á¨…š.ɸ .............................................................……..........................Á¨¤n ..........………..………........................®œoµ......………….…..…...……......…..

‹µÎ œªœš—ɸ œ· ....................................…....................Ŧn.....……………………….....................Šµœ.................……………...….................…....˜µ¦µŠªµ

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Á¨…ž¦³‹Îµ˜ª´ ž¦³µœ
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Á¨…ž¦³‹µÎ ˜ª´ ž¦³µœ
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˜µÎ ¨/…ªŠ ................................. °ÎµÁ£°/Á…˜ ................……..................‹Š´ ®ª—´ ......……......….…..............®¤µ¥Á¨…Ú¦«´¡šr ..............….......…....
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Ö. …oµ¡Á‹µo …°¦´ ¦°Šªµn

(Ò) …oµ¡Á‹oµÅ¤Ån —¦o ´ ðœÂšœ®¦º°Á¡Éº°ž¦³Ã¥œr„n ‡» ‡¨˜nµŠ—oµª

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Á—°º œ…..…………¡.«…….Ážœ} ‹ÎµœªœÁŠ·œ…………………µš
(Ö) Ÿo¼Ä®¥o „Ä®o—oª¥‡ªµ¤Á­œ®n µÅ¤¤n ‡¸ µn ˜°Âšœ ¨ŠÉ°º ..................ª..´œ..š..œ..¸É..µ...¥.......„.........................Á.—...°º ..œ................Ÿ...o…¼ ..°.....Ä..®..o..........…........ ¡.«. ...........…….......
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¨Š°Éº ........................................................... Ÿ¼o­°­ªœ

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­µÎ ®¦´¡œ„´ ŠµœÁ‹oµ®œoµšÉ¸

Ò) ¦µ‡µž¦³Á¤·œšœ» š¦¡´ ¥.r .......................................………........……………...................………….µš..........…….…….............…..............­˜µŠ‡r
Ó) ̜—šÉ—¸ ·œÄ®¤¦n ³ªµŠ...................……....................Á¨…š¸É—·œ..........…....………….......……..........®œµo ­Îµ¦ª‹....................……………...............

̜—š¸—É ·œÁ¨…š.¸É .......................……................….....Á¨n¤.................………….......................……..®œµo …………………..……….………………
‹Îµœªœš¸—É œ· ....................….........………......….......Ŧn...............……......……………....................Šµœ...............……....…........…...........˜µ¦µŠªµ
‡ŠÁ®¨°º .........................................………......….....Ŧn.............……..........……………..............….Šµœ.........…….........…..…..................˜µ¦µŠªµ
Ô) ŗ‹o —š³Á¸¥œÂ¨ªo ˜nªœ´ š.ɸ ..............…...............Á—°º œ...............................¡.«. ……………….
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˜ª´ °¥µn ŠšÉ¸ Õ

(š.—. ÒÕ …)

š¸—É ·œ ®œ´Š­º°­´µÄ®ošÉ¸—œ· ÁŒ¡µ³­ªn œ (¦³®ªnµŠ‹Îµœ°Š)

̜—š.ɸ ......…………………..…….Á¨…š—¸É ·œ..........…....……….……..®œµo ­Îµ¦ª‹...........…………………... ˜µÎ ¨
.......…………..……..…......…°ÎµÁ£°..........…..….….…………...‹´Š®ª—´ ....................................….….....
®œ´Š­º°­´µœ¸Êŗšo εÁ¤°Éº ª´œš…¸É ………………Á—°º œ…………..……….…………¡»š›«´„¦µ………………………
– ­Îµœ´„ŠµœšÉ¸—·œ‹Š´ ®ª´—……………………….……………
Á¨…ž¦³‹Îµ˜ª´ ž¦³µœ

………………………………….….……. † †††† ††††† †† † …. .…
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Á¨…ž¦³‹Îµ˜ª´ ž¦³µœ
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………………………………….…….…. † †††† ††††† †† †
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(Œ´ œ­¸Ê µÎ ®¦´ ………………………………………………)
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(¨Š¨µ¥¤°º ºÉ°Ÿo¼¦´Ä®o)..………………œµ…Š …‹.…………………

(¨Š¨µ¥¤°º °ºÉ ¡¥µœ)…………………………………………..
(¨Š¨µ¥¤º°º°É ¡¥µœ)…………………………………………..
®œŠ´ ­°º ­´ µœ¸ÊŗošÎµ˜°n ®œoµ
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˜´ª°¥nµŠš¸É Õ
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Áœ°ºÊ š—¸É ·œ Áœ°Êº š¸—É œ· ¦³ªµŠ Á‹oµ¡œ´„Šµœš—¸É ·œ
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Ò. œµŠ ‹. Ŧn Šµœ ˜µ¦µŠ Ŧn Šµœ ˜µ¦µŠ
Ó. œµŠ …. ªµ ªµ

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Á—º°œ………… (¦³®ªnµŠ‹Îµœ°Š) Ó. œµŠ ….
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„n œµŠ ‹. Ášµn œ´Êœ ­nªœ…°ŠœµŠ …. ‡ŠÁ—·¤

˜´ª°¥nµŠš¸É Ö † šÉ¸ µo œ (š.—. Ò)

† š­¸É ªœ/Ŧn
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˜ÎµÂ®œnŠšÉ—¸ œ· † ĜÁ…˜

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®œµo ­µÎ ¦ª‹..................Ö....Ù.............................................……..............‹Š´ ®ª´—...........................................................................................……........…….
̜—š¸É—·œ

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Á¨…ž¦³‹Îµ˜ª´ ž¦³µœ

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Á¨…ž¦³‹Îµ˜ª´ ž¦³µœ

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(¨Š¨µ¥¤°º º°É ¡¥µœ)………………………………………………….

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