vuqcU/k &**d**

¼la'kksf/kr½

eq[;ea=kh dU;k nku ;kstuk ds vUrxZr izkFkZuk i=k

¼1½ izkFkhZ ¼yMdh½dk uke%

izkFkhZ dk
QksVksxzkQ

¼2½ tkfr%

¼3½ tUe frfFk%

¼4½ firk@ekrk@laj{kd dk uke%

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fiu dksM &&&&&&&&&&& iapk;r&&&&&&&&&&&&&

rglhy&&&&&&&&&&&&&& ftyk &&&&&&&&&&&&&

¼6½ izkFkhZ dk orZeku irk % xkao &&&&&&&&&&&&&& Mk0&&&&&&&&

fiu dksM &&&&&&&&&&& iapk;r&&&&&&&&&&&&&

rglhy&&&&&&&&&&&&&& ftyk &&&&&&&&&&&&&
¼7½ izkFkhZ ¼yMdh½ ds cSad [kkrk la[;k rFkk 'kk[kk dk uke %

¼8½ izkFkhZ dh 'kS{kf.kd ;ksX;rk

¼9½ yMds dk uke o irk ftlds lkFk fookg fu/kkZfjr gqvk gS ;k gks pqdk gS%

uke ------------------------------------------ firk dk uke ---------------------------- tkfr ------------------------

xkao &&&&&&&&&&Mk0&&&&&&&&&&& fiu dksM &&&&&&&&&&&

iapk;r&&&&&&&&&rglhy&&&&&&& ftyk &&&&&&&&&&&&&

¼10½ yMds dh tUe frfFk%

¼11½ yMds dk orZeku O;olk;%

¼12½ yMds dh 'kS{kf.kd ;ksX;rk

izkFkhZ ds gLrk{kj@ vaxqBs dk fu'kku

?kks"k.kk
k.kk

eS&&&&&&&&&&&&&&&&& iq=kh&&&&&&&&&&&&&&&&&&&&&&&&&
xkao&&&&&&&&&&&&Mk0&&&&&&&&&&&&&&&&rglhy &&&&&&&&

ftyk &&&&&&&&&&&lR;kfu"Bk ysdj vius Kku vuqlkj ;g ?kks"k.kk djrh gwa fd mDr fooj.k rFkk
rF; iw.kZRk% lgh gS A buesa dksbZ ,slk rF; vlR; ugha gS vkSj u gh blesa dksbZ Hkh rF; Nqik;k x;k gS A

izkFkhZ ds gLrk{kj@ vaxqBs dk fu'kku

izkFkZuk&i=k ds lkFk fuEufyf[kr nLrkos
nLrkost layXu fd, tk,a%&

1- yMdk rFkk yMdh ds vk;q dk izek.kA

2- yMdk rFkk yMdh dk fgekpyh izek.k&i=k tks lEcfU/kr jktLo vf/kdkjh ls tkjh gksA
3- yMdh ds ekrk@firk dk okf"kZd vk; izek.k i=k tks lEcfU/kr jktLo vf/kdkjh ls tkjh gksA
4- fookg dh fu/kkZfjr frfFk dk izek.k&i=k
k.k&i=k tks xzke iapk;r@'kgjh fudk;ksa ls tkjh gksA
5- ;fn fookg gks pqdk gS rks fookg iath;d ls tkjh izek.k&i=k dh izfrA

lEcfU/kr cky fodkl ifj;kstuk vf/kdkjh dh lR;kiu fjiksZV%&

izekf.kr fd;k tkrk gS fd

dq0@Jhefr&&&&&&&&&&&&&&&& iq=kh@iRuh &&&&&&&&&&&&&&&&&&& xzke

&&&&&&&&&&&& Mk0 &&&&&&&&&&&&&&& rglhy &&&&&&&&& ftyk &&&&&&&&&

fg0iz0 ds }kjk izkFkZuk i=k esa fn;s x;s iw.kZ rF;ksa dh tkap dh xbZ rFkk ;kstuk ds izko/kkuksa ds vuq:i ik=k gS

A vr% izkFkhZ dks eq[;ea=kh dU;k nku ;kstuk ds vUrxZr lgk;rk jkf'k Lohd`r djus dh flQkfj'k dh

tkrh gSA gLrk{kj

cky fodkl ifj;kstuk vf/kdkjh fnukad%&

¼eksgj lfgr½
 fo/kok iquZfookg ;kstuk

Scheme of Widow Re-Marriage

1. Name of the Applicant (Women)

2. Father's /Guardian's Name
3. Date of Birth
4. Date year of 1st marriage
5. Date/year when she became widow
6. Date of re-marriage
7. Husband's name (who wedlock with widow)
8. Caste
9. Occupation
10. Permanent address
11. Correspondence address
12. Both men and women be bonafide Himachal
(certificate to be attached)

Signature of the applicant

(Women)

Date

Recommendations of the Child Development Project Officer.

 Signature of the

Child Development Project Officer.

Check List:---

1 Marriage registration certificate.

2 Certificate of bonafide Himachal

3 Date of birth certificate

4 death certificate of previous husband

 vuqcU/k&1

fgekpy izns'k ljdkj

lkekftd U;k; ,oa vf/kdkfjrk foHkkx
fgekpy izns'k enj Vsjslk vlgk; ekr` lEcy ;kstuk ¼la'kksf/kr½ 2009
ds fy, izkFkZuk i=k

¼1½ izkFkhZ dk uke% izkFkhZ dk QksVks xzkQ ¼cky

fodkl ifj;kstuk vf/kdkjh
½}kjk lR;kfir½

¼2½ tkfr%

¼3½ tUe frfFk%

¼4½ firk @ifr dk uke%

¼5½ ekrk&firk@ifr esa dkSu thfor gS%

¼6½ vukFk cPpksa ds ekeys esa vfHkHkkod dk uke

¼7½ izkFkhZ dk LFkkbZ irk%

 xkao &&&&&&&&&&&&&& Mk0&&&&&&&&&&&&&&

fiu dksM &&&&&&&&&&& iapk;r&&&&&&&&&&&&&

rglhy&&&&&&&&&&&&&& ftyk &&&&&&&&&&&&&

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fiu dksM &&&&&&&&&&& iapk;r&&&&&&&&&&&&&

rglhy&&&&&&&&&&&&&& ftyk &&&&&&&&&&&&&

¼9½ izkFkhZ ds 18 o"kZ ls de vk;q ds cPpksa dh lwph

dzz0la0 uke tUe frfFk d{kk ftlesa i< jgk gS

¼10½ izkFkhZ dk orZeku O;olk;%

¼11½ izkFkhZ dh 'kS{kf.kd ;ksX;rk

¼12½ D;k izkFkhZZ dks fdlh izdkj dh dksbZ lgk;rk@iSU'ku bR;kfn ljdkj ls feyrh gS

;fn gka rks

 dqy ekfld jkf'k

foHkkx dk uke

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¼1½ 'kk[kk dk uke tgka cpr [kkrk [kqyk gS%

¼2½ cpr [kkrk la[;k%

fnukad %&

izkFkhZ ds gLrk{kj@ vaxqBs dk fu'kku

?kks"k.kk

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xkao&&&&&&&&&&&&&&&&Mk0&&&&&&&&&&&&&&&&rglhy &&&&&&&&&&&&&&

ftyk &&&&&&&&&&&lR;kfu"Bk ysdj vius Kku vuqlkj ;g ?kks"k.kk djrh@djrk gwa fd mDr
fooj.k rFkk rF; iw.kZRk% lgh gS A buesa dksbZ ,slk rF; vlR; ugha gS vkSj u gh blesa dksbZ Hkh rF; Nqik;k
x;k gS A lgk;rk jkf'k Lohd`r gksus ij jkf'k esjs cpr [kkrk la[;k&&&&&&&&&&&&&&&&&&&&&
tks &&&&&&&&&&&&&&&&&& cSd@ Mkd?kj es [kqyk gS es tek dh tk, A *

izkFkhZ ds gLrk{kj@ vaxqBs dk fu'kku

izkFkZuk&i=k ds lkFk fuEufyf[kr nLrkost layXu fd;s tk,as%&

1- izkFkZuk&i=k ds i`"B 3 ij lEcfU/kr iapk;r@'kgjh fudk; ls izek.k&i=k tkjh gksA

 2- xSj ch0ih0,y0 ifjokjksa ls lEcfU/kr izkFkhZ dk okf"kZd vk; izek.k&i=k tks dk;Zdkjh eSftLVªsV ls
tkjh gksA
3- fu%lgk; efgyk gksus@vukFk cPpksa ds vfHkHkkod gksus ds ckjs ikap :i;s ds LVkEi isij ij C;ku
gfYQ;k tks dk;Zdkjh eSftLVªsV ls lR;kfir gksA

* ;fn izkFkhZ ds uke cpr [kkrk cSd@Mkd?kj esa [kqyk ugh gks rks blh izdkj dh opu c}rk lgk;rk jkf'k

Lohd`r djus ds mijkUr izkIr djuh gksxh A

fgekpy izns'k enj Vsjslk vlgk; ekr` lEcy ;kstuk ¼la'kksf/kr½ 2009

izek.k i=k

izekf.kr fd;k tkrk gS fd

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&&&&&&&&&&&&&&&rglhy &&&&&&&&&&& ftyk &&&&&&&&&&&& fg0iz0 dk LFkkbZ
fuoklh gS A

2- Jh@ Jherh &&&&&&&&&&&&&& dh tUe frfFk iapk;r@'kgjh fudk; fjdkMZ vuqlkj &&&&&&&&
¼'kCnksa esa&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&½ gS A

fu%lgk; efgykvksa ds ekeys esa *

3- 1 Jherh &&&&&&&&&&&&&&&& ds 18 o"kZ ls de vk;q ds vkfJr cPpksa ds uke ds lEeq[k n'kkZbZ xbZ
tUe frfFk iapk;r @'kgjh fudk; ds fjdkMZ vuqlkj izekf.kr dh tkrh gS %&

dzz0la0 cPps dk uke cPps dh tUe frfFk

vukFk cPpksa ds ekeys esa *

3- 2 Jh@Jherh &&&&&&&&&&&&&&&& fuEufyf[kr cPps ftuds ekrk&firk dh e`R;q gks pqdh gS rFkk
orZeku esa bu cPpksa dk vfHkHkkod ds :Ik esa ikyu&iks"k.k dj jgsa gSa] fjdkMZ vuqlkj tUe frfFk rFkk muds
ekrk&firk dh e`R;q dh frfFk muds uke ds lEeq[k n'kkZbZ xbZ gS] %&

dzz0la0 cPps dk uke cPps dh tUe frfFk cPps ds ekrk&firk dh e`R;q

dh frfFk

4- Jherh &&&&&&&&&&&&&&&&&& fg0iz0 xzkeh.k fodkl foHkkx @'kgjh fodkl foHkkx }kjk xjhch
js[kk ls uhsps jg jgs ifjokjks ds losZ{k.k vuqlkj dzekd &&&&&&& ftyk &&&&&&&& ds p;fur ifjokj
dk lnL; gSA

gLrk{kj

iapk;r lfpo@lfpo@dk;Zdkjh vf/kdkjh

xzke iapk;r@'kgjh fudk;&&&&&&&

¼eksgj lfgr½

uksV%& * tks ykxw u gks mls dkV nsaA

 lEcfU/kr cky fodkl ifj;kstuk vf/kdkjh dh lR;kiu fjiksZV%&

izekf.kr fd;k tkrk gS fd

Jh@ Jherh &&&&&&&&&&&&&&&& iq=k@iq=kh &&&&&&&&&&&&&&&&&&& xzke

&&&&&&&&&&&& Mk0 &&&&&&&&&&&&&&& rglhy &&&&&&&&& ftyk &&&&&&&&&

fg0iz0 ds }kjk izkFkZuk i=k esa fn;s x;s iw.kZ rF;ksa dh tkap dh xbZ rFkk lgh ik;k x;k A vr% izkFkhZ dks

fgekpy izns'k enj Vsjslk vlgk; ekr` lEcy ;kstuk ¼la'kksf/kr½ 2009 ds vUrxZr lgk;rk jkf'k Lohd`r

djus dh flQkfj'k dh tkrh gSA

gLrk{kj

cky fodkl ifj;kstuk vf/kdkjh

fnukad%& ¼eksgj lfgr½

 efgyk dY;k.k

(Women Welfare)
1- ukjh lsok lnu

(State Homes)

Application form for admission in State Home

1. Name of the applicant

2. Age in the both words and figures
3. Mark of identification
4. Name of Father/Husband
5. Is the father /husband alive?
6. If not, how you have been maintaining/yourself since the death of your
father/husband.

7. Permanent Address
8. Present address
9. Particulars of each earning sons
along with their age.

10. Applicants educational /technical

qualification. if any.

11. Has the applicant an immovable property and

deposit in post office, Bank or Cash in hard,

if so details thereof.

12. Reasons for taking the admission in the Home.

13. Give name and address of the two responsible
persons well known to you who could verify the

correctness of your statement.

 AFFIDAVIT

I -----------------wife/daughter of --------------------resident of --------------

Tehsil--------------------District --------------------------solemnly declare that the particulars given

above are true and correct to the best of my knowledge and belief and nothing has been
concealed.

Signature of the applicant

Recommendations of D.C./ D.W.O. for the admission in the State Home.

 VICITM OF RAPE SCHEME-2012

PROFORMA [UNDER PARA 6(i), Clauses (a) & (b)]

[Where the Application is filed within 60 Days]

(Before filling the proforma, the provisions under the Scheme, Particularly under paras 6 and 8 must be
carefully read)

1. Name of the affected women:

2. Age of the affected women:
3. Name of the parents: (a) Father
(b) Mother
4. Address:

5. Date and Time of the incident:

6. Place of the incident:

7. Name and details of the Applicant:

(if the application is made on behalf or on death of the affected women)

8. Relationship with the affected women (Legal Heir of Any Other, Specify):

9. Whether FIR has been lodged?:

If ‘No’ give reasons thereof.

10.Whether medical examination has been done?:

11. Enclose death certificate (where application is being filed by legal heir)

12. Details of Bank Account:

Date Signature of the applicant

 HIMACHAL PRADESH MAHILA PROTSAHAN YOJNA

FORMAT

1. Name and complete address along-with

Telephone numbers and e-mail address.

2. Area of Award:- Health,Educaion,Sports,

Social Service and Art & Culture.

3. Salient Features of work done

in the field of Award.
4. Year wise contribution
(for the last 5 calendar years)
(i)
(ii)
(iii)
(iv)
(v)

5. Name/Address of recommending agencies along-with

Reasons for recommendations.

 izi=k &1
fgekpy izns'k ljdkj
lkekftd U;k; ,oa vf/kdkfjrk foHkkx

ekrk 'kcjh efgyk l'kfDrdj.k ;kstuk ds fy, izkFkZuk i=k

¼1½ izkFkhZ dk uke% izkFkhZ dk QksVks xzkQ

¼cky fodkl ifj;kstuk vf/kdkjh
}kjk lR;kfir½

(2½ tUe frfFk%

¼3½ firk @ifr dk uke%
¼4½ LFkkbZ irk% xkao &&&&&&&&&&&&&&Mk0&&&&&&&&&&&&&&

fiu dksM &&&&&&&&&&& iapk;r&&&&&&&&&&&&&

rglhy&&&&&&&&&&&&&& ftyk &&&&&&&&&&&&&
¼5½ orZeku irk % xkao&&&&&&&&&&&&&& Mk0&&&&&&&&&&&&&
fiu dksM &&&&&&&&&&& iapk;r&&&&&&&&&&&&&
rglhy&&&&&&&&&&&&&& ftyk &&&&&&&&&&&&&
(6) D;k izkFkhZ ch0 ih0 ,y0 ifjokj ls lEcaf/kr gSaA
(7½ ch0 ih0 ,y0 la0%
(8½izkFkhZ ds cSad [kkrk dk fooj.k
(d½ cSad [kkrk l0 &&&&&&&&&&&&&
([k½ cSad dk 'kk[kk dk uke &&&&&&&&&

¼9½ D;k izkFkhZZ ds ifjokj ds vU; dksbZ lnL; ,y0 ih0 th0 duSD'ku /kkjd g]S ;fn gka fooj.k
fnukad %&
izkFkhZ ds gLrk{kj@ vaxqBs dk fu'kku

?kks"k.kk
eS&&&&&&&&&&&&&&&&&iq=k@iq=kh@iRuh&&&&&&&&&&&&&&&&&&&&&&&&

xkao&&&&&&&&&&&&Mk0&&&&&&&&&&&&&&&&rglhy&&&&&&&&&&&&&&ftyk

&&&&&&&&&&&lR;kfu"Bk ysdj vius Kku vuqlkj ;g ?kks"k.kk djrh gwa fd mDr fooj.k rFkk rF; iw.kZRk%

lgh gS A buesa dksbZ ,slk rF; vlR; ugha gS vkSj u gh blesa dksbZ Hkh rF; Nqik;k x;k gS A

izkFkhZ ds gLrk{kj@ vaxqBs dk fu'kku

izek.k i=k

izekf.kr fd;k tkrk gS fd%&

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&&&&&&&&&&&&&&&rglhy &&&&&&&&&&& ftyk &&&&&&&&&&&& fg0iz0 dk LFkkbZ
fuoklh gS A
2- Jherh &&&&&&&&&&&&&&&&&& xjhch js[kk ls uhsps jg jgs ifjokjks ds losZ{k.k vuqlkj dzekad
&&&&&&& ftyk &&&&&&&& ds p;fur ifjokj dk lnL; gSA

3] Jherh&&&&&&&&&ds ifjokj ds vU; dksbZ Hkh lnL; ds ,y ih th xSl duSD'ku /kkjd ugh gSaA
 gLrk{kj gLrk{kj

iapk;r lfpo@lgk;d iz/kku xzke iapk;r@'kgjh fudk;

xzke iapk;r@'kgjh fudk; + + + + + + + + + + + + + + + + + + + + + + + + + + + + eksgj lfgr + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

;fn ykxw ugh gS rks dkV ns A

lEcfU/kr cky fodkl ifj;kstuk vf/kdkjh dh lR;kiu fjiksZV%&

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rFkk lgh ik;k x;k A vr% izkFkhZ dks ekrk 'kcjh vlgk; efgyk lEcy ;kstuk ds vUrxZr minku jkf'k
Lohd`r djus dh flQkfj'k dh tkrh gSA gLrk{kj

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fnukad%& ¼eksgj lfgr½