kmaqlykpcms]j At]m t^mdw

kmaqlykpcm s]js t]cv : tZiob hmIyIme s]j

For Office use only
s]j\ \ :

s]j\dpsS
Ign 6amk
n\pn
FSp ]mkvt]m
v Afhnep
t^mtm ChnsS
HnWw

s]j\ tImUv :

At]m \ :
C\w
1. KpWt`mmhns/ s]j\dpsS t]cv
(C\ojy t]cn\v tijw tcJsSpWw)

i. aebmfn :
ii. Cwojn :
2.

i. P\\ XobXn/ ({InkvXphjw) :

ii. hbv :

Znhkw

amkw

hjw

hjw

3. ]qamb tahnemkw (DZmlcWw

t\mpI)

i. hov t]cv :
ii. sInS\

hjw

hmUv \

hov \

1995
2000
2005

iii. dknUvkv Atkmkntbj\nep

hov \ :
iv. dknUvkv Atkmkntbjs t]cv :
v. c/o tahnemkw :
vi. hoSns m\w kqNnnpXn\v km
[mcW D]tbmKn mdp {][m\ `ua
kqNIw (DZm: km m]\w, Bcm
[\mebw, ivaim\w, _mv, kzImcy m]
\w {Smkvt^ma FnhbntesXnepw.)

vii. hoSv nXnsNp tdmUns/sXcphns

/IhebpsS/{]mtZinI ens t]cv :
viii. {][m\ etcv (hoSv nXnsNp
ehpw kao]{]tZifpw DsSp
`mKn\p s]mXphmb t]cv) :
ix. tImtdj\n s]j\dpsS hoSv
nXn sNp ]pXnb CevIvSd
hmUns t]cpw \dpw (2005 se) :

x. t]mm^okns t]cpw ]ntImUpw

t]mm^okns t]cv

]ntImUvv

4. ]pcpj/kv{Xo :
5. AhiXbpsS kz`mhw :
6. hn`mKw :

s]mXp hn`mKw

]nIPmXn

]nIhKw

7. tIcfn Xmaknambnv F{X hjambn :

1

8. KpWt`mmhns/ s]j\dpsS t]cv Dsnp tdj ImUns \ * :

9. _n.]n.F ImUv \ ** :
10. CeIvSd Xncndnb ImUv \ *** :
Ipdnv :-

*. tdjImUns BZys t]Pnsbpw KpWt`mmhns/ s]j\dpsS hniZmwi

tcJsSpnb t]Pnsbpw t^mtmtImn CXnt\msSmw lmPcmWw.

**. e`yamsWn (Zmcn{ZytcJbv Xmsgbph am{Xw).

***. CeIvSd ImUns CcphifpsSbpw t^mtmtImn CXnt\msSmw lmPcmWw.

11. \nehnep hmUv IuknedpsS t]cv:

At]I() IpjvTw/bw/A_pZw Fnhbvp

XmsX atsXnepw B\pIqyw/s]j
ssI]pptm?

Dv :

C :

At]I() AKXnbmtWm?

AsX :

A :

AKXnancnse AthmknbmtWm?

AsX :

A :

At]I() amcpsSsbnepw B{inX\mtWm?

AsX :

A :

bmNI BtWm?

AsX :

A :

hnhmlnX\m(bm)tWm?

AsX :

A :

`mcy/`mhv Pohnncnptm?

Dv :

C :

{]mb]qnbmb BafpsS Fw
{]mb]qnbmb AhnhmlnXcmb s]afpsS
Fw
aq aIs {]mbw, P\\ XobXn ({InkvXphjw) :

hniZamb hcpam\ kn^nv lmPcmnbnptm?

Znhkw
Dv :

amkw

hjw

C :

BsI hmjnI hcpam\w

Phone No. / Contact No.

ew :
XobXn :

KpWt`mmhns Hv