`vwqz¡ n¯—vš —i cÎ (e`wj/ kgwe‡”q‡`i ... -...

144

ms‡hvRbx- 14/12

`vwqZ¡ n¯—vš—i cÎ (e`wj/ Kg©we‡”Q‡`i †¶‡Î)

1. `vwqZ¡ n —vš—iKvixi bvg: ..........................................................................................................................

c`we: ........................................................ wcb:....................................†eZb —i:..................................

2. `vwqZ¡ MÖnYKvixi bvg: .............................................................................................................................

c`we: ........................................................ wcb:....................................†eZb —i:..................................

3. GjvKv:....................................................... AÂj: .................................Kg©m~wP: .....................................

4. eª v‡K †hvM`v‡bi ZvwiL: ............................................ eZ©gvb GjvKvq †hvM`v‡bi ZvwiL: ......................................

5. eZ©gvb GjvKvq †h ZvwiL ch©š— Kg©iZ wQ‡jb:.................................................................................................

6. Am¤úbœ KvR (hw` _v‡K): .........................................................................................................................

7. n —vš—‡ii dvBj I WKz‡g›Umg~n †hgb- †gvUi mvB‡Kj, Rwgi `wjjcÎ I Ab¨vb¨ `wjj ` —v‡eR: †gvU msL¨v (we —vwiZ ZvwjKv mshy³ Ki‡Z n‡e|

8. wnmve msµvš— Z_¨

(K) e¨vs‡K Rgv A‡_©i e¨v‡jÝ UvKv:.........................................ZvwiL: ..................................................

(L) bM` A‡_©i e¨v‡jÝ UvKv: .................................................ZvwiL: ..................................................

(M) †PK eB‡qi weeiY: (1) †PK b¤i:...........................................n‡Z .......................................................(¯v¶imn)

(2) †PK b¤i:...........................................n‡Z ....................................................(¯v¶iwenxb)

`vwqZ¡ n —vš—‡ii ZvwiL:

`vwqZ¡ n —vš—Kvixi ¯v¶i: `vwqZ¡ MÖnYKvixi ¯v¶i:

1. mv¶xi ¯v¶i:

bvg: ........................................................................

c`we:...........................................wcb:......................

2. mv¶xi ¯v¶i:

bvg: ........................................................................

c`we:....................................... wcb:.........................

Abywjwc:

(K) mswkó Kg©m~wP/ wefvMxq cÖavb (M) Awdm bw_ (N) wbR¯ Kwc

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145

ms‡hvRbx- 14/13 e`wji Av‡`k bs:..............................

e`wji AvBwW bs:.............................. e`wj cieZ©x †hvM`vbcÎ

Kg©x KZ©„K c~iYxq

bvg:------------------------------------------------------------ wcb:------------ †eZb —i: ------------- wcGd b¤i: ---------- eª v‡K †hvM`v‡bi ZvwiL: ------------------------------ e`wji ZvwiL (e`wji Av‡`k Abyhvqx): -----------------------------------

ee`wwjjii wweeeeiiYY e`wj c~e©eZ©x Kg©m~wP: e`wj cieZ©x Kg©m~wP:

e`wj c~e©eZ©x Kg© ’j: e`wj cieZ©x Kg© ’j:

e`wj c~e©eZ©x c`we: e`wj cieZ©x c`we:

c~e©eZ©x Kg© ’j †_‡K cÖ ’v‡bi ZvwiL: mgq:

bZzb Kg© ’‡j ‡hvM`v‡bi ZvwiL: mgq:

KKgg©©xxii wwVVKKvvbbvv

’vqx wVKvbv: MÖvg/ gnjv: ....................................................... WvKNi: .................................................................. _vbv: ............................................. ‡Rjv: .......................................... †dvb (†gvevBj): ......................................

eZ©gvb wVKvbv: evm ’vb (†h ’vb †_‡K Kg©xi Kg© ’‡ji ~iZ¡ wba©vib Kiv n‡e): †Rjv ..........................................................

mmsswwkk óó wwnnmmvvee wweeffvvMM // ggvvbbeemm¤¤úú` wweeffvvMM KKZZ©© „„KK cc~~iiYYxxqq (gvV Kvh©vj‡qi †¶‡Î wnmve wefvM Ges cÖavb Kvh©vj‡qi †¶‡Î gvbem¤ú` wefvM c~iY Ki‡e)

‡‡eeZZ‡‡bbii wweeeeiiYY

††eeZZbb wweeeeiiYYxx ee`wwjj cc~~ee©©eeZZ©© xx ††eeZZbb (UvKv) ee`wwjj cciieeZZ©©xx ††eeZZbb (UvKv)

g~j †eZb evwofvov fvZv cÖKí evwofvov mnvqZv fvZv wPwKrmv fvZv hvZvqvZ fvZv Dc‡hvM Ab¨vb¨ (D‡jL Ki“b) †_vK ‡eZb †gvU †eZb mxjmn ¯v¶i I ZvwiL:

ee`wwjj cc~~ee©©eeZZ©© xx AAwwddmm KKZZ©© „„KK cc~~iiYYxxqq

e`wj c~e©eZ©x Kg© ’‡j †h ZvwiL ch©š— †eZb cÖ vb Kiv n‡q‡Q: -------------------------------------------------------------------- FFYY (hw` _v‡K): †h ‡Kvb ai‡bi FY ev AwMÖg MÖn‡Yi weeiY (e‡Kqv _vK‡j FY gÄywicÎ ms‡hvRb Ki‡Z n‡e)

- eZ©gvb e‡Kqv: Avmj (UvKv): ............................ my (UvKv): ......................... ‡gvU (UvKv):.................................

- Ab¨vb¨ †`bv/ cvIbv ev †Kvb gš—e¨ hw` _v‡K: ...................................................................................................

- †gvUi mvB‡Kj FY MÖn‡Yi ZvwiL: ..................................... F‡Yi cwigvY (UvKv): ...............................................

.......................ZvwiL ch©š— Av`vq (UvKv): ........................................ Ges evwK (UvKv): ....................................

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Kg©x Kj¨vY mÂq (hw` _v‡K) : Kg©x hw` Kg©x Kj¨vY mÂq cÖK‡íi m`m¨ n‡q _v‡K Zvi we —vwiZ Z_¨ cÖ vb Ki‡Z n‡e: - gvwmK mÂq cÖKí wnmve b¤i.......................... wnmve †Lvjvi ZvwiL.........................gvwmK wKw —i cwigvY .....................

me©‡gvU Rgvi cwigvY.......................

- wØ¸Y Rgv cÖK‡íi wnmve b¤i ................. wnmve †Lvjvi ZvwiL ............................me©‡gvU Rgvi cwigvY ..........................

QywU - eZ©gvb Kg© ’‡j †kl Kg©w`em ..................................... ZvwiL ch©š— cvIbv QywU .............................................. w`b| - eva¨Zvg~jK QywUi weeiY (QywU wb‡q _vK‡j mgq D‡jL Ki‡Z n‡e)........................................................................... - gvZ„Z¡/ wcZ…Z¡RwbZ QywUi weeiY (Kg©x QywU †fvM K‡i _vK‡j we —vwiZ wjL‡Z n‡e)

1. ...................................... ZvwiL n‡Z ....................................... ZvwiL ch©š— †gvU .............................. w`b| 2. ...................................... ZvwiL n‡Z ....................................... ZvwiL ch©š— †gvU .............................. w`b|

e`wj - Kg©x †¯”Qvq e`wj n‡q‡Q wK bv? nu v / bv (wUK wPý ( ) w`‡Z n‡e)

Kg©xi e`wjRwbZ QzwU: e wj RwbZ QzwU ------------------------------------- ZvwiL n‡Z ------------------------------------- ZvwiL gÄyi Kiv n‡jv|

Kg©xi wbKU †Kvb cvIbv/ gš—e¨ _vK‡j wjL‡Z n‡e (ïay cÖavb Kvh©vj‡qi Rb¨ cÖ‡hvR¨)::

hvbevnb wefvM -------------------------------------------------------------- MÖš’vMvi ------------------------------------

gvbem¤ú` wefvM ----------------------------------------------------------- †Uwj‡dvb wefvM ----------------------------

------------------------------------------ wnmve Kg©KZ©v / gvbem¤ú` Kg©KZ©vi ¯v¶i

bvg: -------------------------------------------------------

c`we: -------------- Kg© ’j------------------- wcb:--------

ZvwiL: -----------------------------------------------------

-------------------------------------

ZË¡veavq‡Ki ¯v¶i

bvg: -------------------------------------------------------

c`we: -------------- Kg© ’j------------------- wcb:-------- ZvwiL: -----------------------------------------------------

e`wj cieZ©x Awdm KZ©„K c~iYxq

Kg© ’‡ji bvg: -------------------------------GjvKv:----------------------------AÂj:--------------------------------------

‡Rjv:----------------------------------------†hvM`v‡bi ZvwiL: --------------------------------- mgq: ---------------------

e`wj cieZ©x Kg© ’‡j Awdm Avevmb e¨envi Ki‡e wK bv ? nu v / bv (wUK wPý w`‡Z n‡e)

-------------------------------------

†hvM`vbKvix Kg©xi ¯v¶i bvg: ---------------------------------------------------- wcb:---------------------- ZvwiL: -------------------

-------------------------------------

ZË¡veavq‡Ki ¯v¶i bvg: ------------------------------------------------------- c`we: ----------------------------- Kg© ’j ----------------wcb: -------------ZvwiL: ----------------------------------

mmss‡‡hhvvRRbbxx : (wb‡gœ D‡jwLZ KvMRcÎvw` e`wj cieZ©x †hvM`vbc‡Îi mv‡_ mshy³ K‡i e`jx ciewZ© Kg© ’‡j Rgv w`‡Z n‡e) - `vwqZ¡ n —vš—ic‡Îi Kwc - Kg©x eZ©gvb GjvKvq g~j¨vqb eQ‡ii hZw`b wQ‡jv Zvi Dci wfwË K‡i g~j¨vqbK„Z g~j¨vqbcÎ - FY gÄywicÎ (hw` e‡Kqv _v‡K)

Abywjwc: 1. mswkó gvbem¤ú` Kvh©vjq 2. A_© I wnmve wefvM

3. e`wj c~e©eZ©x Kg© ’j 4. e`wj cieZ©x Kg© ’j

Kg©©x‡K e`wji AvBwW bs Aek¨B msMÖn Ki‡Z n‡e|

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147

ms‡hvRbx- 14/14 Awdm Avevm‡b Ae ’v‡bi Rb¨ Av‡e`b

Avwg..........................................................................................wcb...................c`we.....................................

¯—i:..........................Kg©m~wP:.......................................................kvLv: ............................................................

GjvKv:............................................AÂj:..........................................†Rjv: ...................................................

G Kg©iZ AvwQ| ........................................ ZvwiL †_‡K mswkó ZË¡veavq‡Ki Aby‡gv`b mv‡c‡¶ Awdm Avevm‡b Ae ’vb

Ki‡Z PvB|

Kg©xi ¯v¶i:

ZvwiL:

mswkó ZË¡veavq‡Ki Aby‡gv`b:

................................................................. ZvwiL n‡Z Awdm Avevm‡b Ae¯’v‡bi Rb¨ Aby‡gv`b †`qv n‡jv|

¯v¶i:...........................................ZvwiL:..............................................................wcb:...............................

bvg: ...............................................................................c`we:.................................................................

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148

ms‡hvRbx- 14/15

Awdm hvb eënv‡ii Rb¨ Av‡e`b (cÖavb Kvh©vj‡qi Rb¨ cÖ‡hvR¨)

wcK GÛ Wªc/ i“U cwieZ©b/ wmU evwZj Av‡e`bKvixi bvg: …………………………………………….…… wcb: .……………… cèx: …………………….……..

—i/ †MÖW: ……..…… Kg©x aiY: ………………...........……..……….. Kg©m~wP/ wefvM : ……………………………………....

‡dvb b¤i : ewa©Z …………….....………… ‡gvevBj: ………………………………………………………………………..

wcK GÛ Wªc

wVKvbv: ………………………………………………………………………………....…………………….....................

Kvw•LZ i“U: ………...............................………………. hvb eënv‡ii m¤¢ve¨ ZvwiL: ………………………………………....

¯v¶i: …………………..…… ZvwiL: ………………………

mycvwikKvix (wefvMxq cÖavb/ †mKkb cÖavb): ¯v¶i ………………………. cèx: …………………………….

i“U cwieZ©b

wVKvbv:: ……………………………………………………………………………………………………........................

eZ©gvb i“U : ………………………………. Kvw•LZ i“U: ……………………………………………………………….......

i“U cwieZ©‡bi KviY: ……………………………………………………………………………………………………......

hvb eënv‡ii m¤¢ve¨ ZvwiL: ……………………………………………………………………………………......................

¯v¶i: …………………..…… ZvwiL: ………………………

mycvwikKvix (wefvMxq cÖavb): ¯v¶i ………………………. cèx: …………………………….

wmU evwZj i“U : ……..…… wmU evwZ‡ji m¤¢ve¨ ZvwiL: ……………… wmU evwZ‡ji Kvib: ……………………………

¯v¶i: …………………..…… ZvwiL: ………………………


gvZ…Z¡RwbZ QywU msµvš— Z_¨ i“U : ……..……....QywU: ……….….….ZvwiL ‡_‡K ………..…… ZvwiL †hvM`v‡bi m¤¢ve¨ ZvwiL: ………….…………….....

¯v¶i: …………………..…… ZvwiL: ………………………


hvbevnb wefvM KZ…K© c~ibxq Av‡e`b cÎ MÖn‡bi ZvwiL: …………………… hvbevnb Kg©KZ©vi ¯v¶i: …………………….. ZvwiL: ………....………….…..

cÖ vbK…Z evnb b¤i: …………………… i“U : …………..…… Kvh©K‡ii ZvwiL: ……………………………….…………......

wmU cÖ vb bv Kivi KviY: ……………………………………………......…………………………………………………....

wmU evwZj (Kvh©K‡ii ZvwiL): ………………………………...…………………………………………………………........

gš—e¨: ……………………………………………………………………………………………………………………..

we: ª: GB digwU Av‡e`bKvix c~iY K‡i hvbevnb wefv‡M cvVv‡e|

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ms‡hvRbx- 14/16 Mvoxi Pvwn`vcÎ (`vßwiK Kv‡R)

Pvwn`vcÎ MÖnYKvixi bvg: ................................................................................................. hvÎx msL¨v: ....................... ZvwiL I mgq: ....................................................................................... Mvoxi aiY: .............................................. Pvwn`vcÎ b¤i: ...................................................................................................................................................... ................... ZvwiL, †ivR ........................ mKvj/ weKvj .................. Uv n‡Z ...................... ZvwiL, †ivR ..................... mKvj/ weKvj ......................... Uv ch©š— `vßwiK Kv‡R eënv‡ii Rb¨ Avgvi bv‡g AbyMÖn c~e©K GKwU Mvox eivÏ Ki“b| wejwU ............................................... wnmve Lv‡Z Aš—f©y³ Kivi Rb¨ Aby‡iva Kiv nj| MvwowU wb‡gœ D‡jwLZ c‡_ PjvPj Ki‡e|

hvÎv ’j Mš—e¨ ’j åg‡Yi wbw ©ó KviY

Pvj‡Ki bvg:.......................................... eënviKvixi bvg: ................................... ¯v¶i: ..............................

wcb: .................................................... wcb: ................. c`we : ..................................... —i: ....................

Mvwoi b¤i:............................................ wefvM: ............................................... ZvwiL: .......................... ..... Aby‡gv`bKvix Kg©xi ¯v¶i wefvMxq Aby‡gv`b ...........................................................................................................................................................................

Pvwn`vcÎ b¤i cÖwZ wjUv‡i Mvwo †`Šovq: AwZwi³ c„ôv

hvÎv Mš—e¨ †gvU ivwÎhvcb Ifvi Kg©wèm ZvwiL ’vb wgUvi mgq ’vb wgUvi mgq wK.wg. mgq n¨vu/bv UvBg QywU

†gvU= ZvwiL Pvjvb weeiY mieivnKvix †Z‡ji wnmve (wjUvi) I g~j¨ †Zj i¶Yv‡e¶Y

b¤i †Zj †bIqv g~j¨ hvÎvi ïi“‡Z †gvU LiP cwigvY g~j¨

Pvj‡Ki ¯v¶i ................................ fzw³i ZvwiL .....................................Pvj‡Ki bvg ........... ...................................

fzw³Kvix ................................................................................ Mvwo eënviKvixi ¯v¶i ............................................

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150

ms‡hvRbx- 14/17 Mvoxi Pvwn`vcÎ

(e¨w³MZ Kv‡R eënv‡ii Rb¨)

Pvwn`vcÎ MÖnYKvixi bvg: .................................................................. hvÎx msL¨v: .............................. ZvwiL I mgq: ................................................................................ Mvoxi aib: ............................. Pvwn`vcÎ b¤i: ............................................................................... ....................... ZvwiL, †ivR......................... mKvj/weKvj .................. Uv n‡Z .......................ZvwiL, †ivR ................... mKvj/weKvj ................Uv ch©š— e¨w³MZ Kv‡R eënv‡ii Rb¨ Avgvi bv‡g AbyMÖn c~e©K GKwU Mvox eivÏ Ki“b| wejwU ............................................. wnmve Lv‡Z Aš—f©y³ Kivi Rb¨ Aby‡iva Kiv nj| MvwowU wbgœwjwLZ c‡_ PjvPj Ki‡e|

hvÎv ’j Mš—e¨ ’j åg‡Yi wbw ©ó KviY

Pvj‡Ki bvg:.................................................. eënviKvixi bvg: ....................................... ¯v¶i: ...................

wcb: ........................................................... wcb: ............. c`we : ...................................... —i: .............

Mvwoi b¤i:................................................... wefvM: ................................................. ZvwiL: ..................

Mvox e›UbKvix Kg©xi ¯v¶i wefvMxq Aby‡gv`b

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

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

Pvwn`vcÎ b¤i cÖwZ wjUv‡i Mvwo †`Šovq: AwZwi³ c„ôv

hvÎv Mš—e¨ †gvU ivwÎhvcb Ifvi Kg©wèm ZvwiL ’vb wgUvi mgq ’vb wgUvi mgq wK.wg. mgq n¨vu/bv UvBg QywU

†gvU= ZvwiL Pvjvb weeiY mieivnKvix †Z‡ji wnmve (wjUvi) I g~j¨ †Zj i¶Yv‡e¶Y

b¤i †Zj †bIqv g~j¨ hvÎvi ïi“‡Z †gvU LiP cwigvY g~j¨

Pvj‡Ki ¯v¶i ................................ fzw³i ZvwiL ...........................Pvj‡Ki bvg ................................ .........................

fzw³Kvix ................................................... Mvwo eënviKvixi ¯v¶i ..........................................................................

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ms‡hvRbx- 14/18

ågY Aby‡gv`bcÎ

bvg .............................................................wcb..............c`we .............................. Kg© ’j ....................................

Kg©m~wP/wefvM .........................................................................................Mš—e¨ ’j ..................................................

ågY ïi“i ZvwiL ........................... mgq.................. åg‡Yi D‡Ïk¨ ..................................................... ....................

................................................................. m¤¢ve¨ †divi ZvwiL.................................

Av‡e`bKvixi ¯v¶i................................................ ZvwiL .........................

Aby‡gv`bKvixi ¯v¶i .........................................................

bvg ...................................wcb........................................

c`we .............................................................................

ågY †k‡l c~iY Ki‡Z n‡e: cÖK…Z †divi ZvwiL ........................................... mgq....................................................................................

m¤¢ve¨ †divi ZvwiL cwieZx©Z n‡j Zvi KviY .......................................................................................................... Aby‡gv`bKvixi ¯v¶i ..................................................ZvwiL .............................................................................

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ms‡hvRbx- 14/19 INTERNATIONAL TRAVELING AUTHORISATION FORM

1. PERSONAL DETAILS: NAME: PIN: LEVEL :

DESIGNATION: PROGRAM: DUTY STATION:

PASSPORT NO : DATE OF ISSUE : MARITAL STATUS :

2. DETAILS OF TRAVELING PROGRAMME: PURPOSE / JUSTIFICATION OF THE VISIT:

CITY: VENUE ADDRESS:

COUNTRY: DURATION OF THE VISIT FROM: TO: TOTAL DAYS:

OFFICIAL VISIT FROM: TO: TOTAL DAYS: LEAVE TAKEN (IF ANY) FROM: TO: TOTAL DAYS:

DETAILS OF EXPENSES

TOTAL AMOUNT: BY BRAC : BY SPONSOR :

PERSONAL (IF APPLICABLE) :

DATE OF DEPARTURE FROM DHAKA:

DATE OF ARRIVAL AT DHAKA:

DATE OF JOINING AT DUTY :

3. PLACE OF STAY IN ABROAD: ADDRESS :

TELEPHONE: FAX:

E-MAIL:

4. DETAILS OF ORGANISER/S: NAME: ADDRESS :

TELEPHONE: FAX:

E-MAIL: 5. DETAILS OF SPONSOR/S:

NAME: ADDRESS :

TELEPHONE: FAX: E-MAIL:

SIGNATURE OF THE APPLICANT:

DATE:

6. RECOMMENDATION

SUPERVISOR PROGRAM HEAD/ ASSOCIATE

DIRECTOR/ DIRECTOR/ DEPUTY EXECUTIVE DIRECTOR

DIRECTOR FINANCE DIRECTOR HUMAN RESOURCE

7. APPROVAL

EXECUTIVE DIRECTOR/ MANAGING DIRECTOR

Note: Please attach supporting papers. For example, letter of invitation/ sponsorship, ticket etc.

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ms‡hvRbx- 14/20

`~iZ¡ fvZvi Av‡e`b cÎ

ZvwiL: ..............................................

cÖwZ: ................................................ Kg©m~wP: ............................................ GjvKv:......................................AÂj: ..........................................

welq: `~iZ¡ fvZv cÖvwßi Rb¨ Av‡e`b|

Rbve

Avwg ............................................................................. wcb: .................... c`we: .................................

¯—i: ................ Kg©m~wP: ............................... kvLv: ................................. GjvKv: ....................................

AÂj: ............................. G Kg©iZ AvwQ| Avgvi wbR / cwiev‡ii evm ’vb:

Dc‡Rjv ............................................................................ †Rjv ......................................................

Dc‡i D‡jwLZ mKj Z‡_ï mZ¨Zvi Dci wfwË K‡i Avwg ~iZ¡ fvZvi Rb¨ Av‡e`b KiwQ| AZGe, Avgv‡K ~iZ¡ fvZv cÖvwßi Rb¨ Aby‡gv`b w`‡q evwaZ Ki‡eb|

wb‡e`K

¯v¶i: ................................................................ ZvwiL: ........................................................

mswkó wnmve wefvM KZ©„K c~iYxq:

‡eZb ¯—i Abyhvqx `~iZ¡ fvZv: ....................... UvKv (K_vq: ...........................................................) cÖvc¨ n‡eb|

¯v¶i: ................................................. ZvwiL: .......................................... wcb: .................................

bvg: .................................................................. c`we: .....................................................................

mswkó ZË¡veavq‡Ki Aby‡gv`b:

....................................................... ZvwiL n‡Z `~iZ¡ fvZvi Aby‡gv`b †`qv n‡jv|

¯v¶i: ............................................. ZvwiL: ................................................. wcb: ..............................

bvg: .................................................................................. c`we: ......................................................

we: ª: - †¯”Qvq e`wji †¶‡Î GB fvZv cÖ‡hvR¨ n‡e bv| - Kg© GjvKv cwieZ©b n‡j c~‡e©i Aby‡gv b evwZj e‡j MY n‡e Ges cÖ‡hvR †¶‡Î Kg©x bZzb GjvKvq †hvM`v‡bi ci cybivq yiZ¡ fvZvi Rb Av‡e`b

Ki‡Z cvi‡e| - gv‡mi †kl Kg© wèm n‡Z ciewZ© gv‡mi †h †Kvb Kg©wè‡m Kg©x GB fvZv wnmve wefvM n‡Z †WweU fvDPv‡ii gva¨‡g D‡Ëvjb Ki‡Z cvi‡e| - ZË¡veavq‡Ki ¯v¶i mn Av‡e`‡bi GK Kwc mswkó wnmve wefv‡M Rgv w`‡Z n‡e|

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154

ms‡hvRbx- 14/21

Awdm mg‡qi AwZwi³/ e‡Üi w`‡b KvR Kivi Pvwn`vcÎ

wefvM/Kg©m~wP: †d¬vi:

ZvwiL:

Pvwn`vKvixi bvg ................................................................... Aby‡gv`bKvix (17Zg ev Z`~aŸ© —‡ii ZË¡veavqK)

¯v¶i ................................................................................ ¯v¶i ..............................

bvg ..............................................................

‡d¬vi g¨v‡bRvi .................................................................... wcb.................................

cèx ............................................................

wb‡gœ D‡jwLZ eª vK Kwg©MY Awdm QywUi ci/ QywUi w`‡b KvR Ki‡e

mgq µwgK bs

Kg©xi bvg I wcb cèx ZvwiL n‡Z ch©š—

AwZwi³ mgq KvR Kivi D‡Ïk¨

1

2

3

4

5

6

7

8

9

10

KvR †k‡l c~iY Kivi Rb¨

KvR †kl nIqvi mgq .............................................. wb‡qvwRZ wbivcËvKg©xi bvg ...............................................

¯v¶i...................................................................

`j‡bZvi bvg.........................................................

we:`ª: KvR †kl nIqvi ci GKRb wbivcËv cÖnix‡K Awdm K‡¶ Zvjv †Ìqvi Rb¨ WvK‡e Ges wbivcËv Kg©xi Dcw ’wZ‡Z GB d‡g© ¯v¶i Ki‡e|

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ms‡hvRbx- 14/22 Awdm mg‡qi AwZwi³/ e‡Üi w`‡b KvR Kivi wej

Kg©xi bvg: ............................................................................................ wcb:........................ —i:.........................

c`we: ................................................................... Kg©m~wP/ wefvM: ........................................................................

KvR Kivi mgq ZvwiL evi Kv‡Ri aib

nB‡Z ch©š— †gvU mgq

(NÈv) AwaKvj

fvZvi nvi hvZvqvZ

fvZv Lvevi fvZv

†gvU

we‡ji mv‡_ Awd‡m Avmv Ges hvIqvi †mvqvBc (Attendance) wi‡cvU© mshy³ Ki‡Z n‡e|

Kg©xi ¯v¶i: ......................................................

ZvwiL: ..............................................................

Aby‡gv`bKvixi ¯v¶i: .....................................

bvg:..............................................................

c`we:............................................................

wcb: ........................... —i: ............................

ZvwiL:...........................................................

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ms‡hvRbx- 14/23 D”Pwk¶v/ cÖwk¶‡Yi Av‡e`b/ g‡bvbqb cÎ

1. Kg©xi weeib t bvg: wcb : cèx : —i : ‰eevwnK Ae ’v: Kg©m~wP : eZ©gvb Kg© ’j : AÂj : me©‡kl wk¶vMZ †hvM¨Zv : eª v‡K †hvM`v‡bi ZvwiL :

2. wbR D‡`¨v‡M Av‡e`bK…Z / eª vK KZ…©K g‡bvbxZ [wUK wPý w`b]

3. D”Pwk¶v/ cÖwk¶‡Yi bvg : D”Pwk¶v/ cÖwk¶‡Y AskMÖn‡Yi ’vb :

4. D”Pwk¶v/ cÖwk¶Y cwiPvjbvKvix cÖwZôv‡bi weeib t bvg : wVKvbv : †Uwj‡dvb : d¨v· :

B-‡gBj : 5. D”P wk¶v/ cÖwk¶‡Y AskMÖn‡Yi †hŠw³KZv :

6. e¨qenbKvix ms ’vi bvg :

(cÖ‡hvR¨ †¶‡Î cÖ‡qvRbxq KvMRcÎ mshy³ Ki‡Z n‡e|)

7. D”Pwk¶v/ cÖwk¶‡Yi mgqKvj nB‡Z : ch©š— :

D”Pwk¶v/ cÖwk¶YKvjxb QywUi weeiY (cÖ‡hvR¨ †¶‡Î) nB‡Z : ch©š— :

D”Pwk¶v/ cÖwk¶YKvjxb QywU‡Z _vKvKvjxb cwievi †i‡L hv‡eb/ cwievi m‡½ wb‡q hv‡eb (wUKwPý w`b)

8. D”Pwk¶v/ cÖwk¶‡Yi m¤¢ve¨ e¨q :

9. Avš—R©vwZK D”Pwk¶v/ cÖwk¶‡Yi †¶‡Î XvKv †_‡K hvÎvi ZvwiL : XvKvq †divi ZvwiL : Awd‡m †hvM`v‡bi ZvwiL:

10. Kg©xi ¯v¶i : ZvwiL :

11. mswkó ZË¡veavq‡Ki mycvwik :

¯v¶i : ZvwiL : 12. wØZxq ZË¡veavqK/ Kg©m~wP cÖavb/ mn‡hvMx cwiPvjK/ cwiPvjK/ Dc-wbe©vnx cwiPvj‡Ki mycvwik : ¯v¶i : ZvwiL : 13. gš—e¨ : cwiPvjK A_© I wnmve ¯v¶i I ZvwiL:

cwiPvjK, gvbem¤ú` ¯v¶i I ZvwiL :

15. cwiPvjK/ Dc-wbe©vnx cwiPvjK/ wbe©vnx cwiPvjK/ eë ’vcbv cwiPvj‡Ki Aby‡gv`b :

¯v¶i : ZvwiL :

wet `ªt - eª v‡Ki Af¨š—ixY cÖwk¶‡Yi †¶‡Î GB Av‡e`bcÎ cÖ‡hvR¨ bq | - †Kvb Kg©x wbR D‡`¨v‡M D”Pwk¶v ev cÖwk¶‡Yi eë¯’v Ki‡j Ges eª vK AbygwZ w`‡j D³ D”Pwk¶v/ cÖwk¶YKvjxb QywU webv‡eZ‡b n‡e

Ges Kg©x ms¯’v †_‡K †Kvb ai‡bi my‡hvM-myweav cv‡e bv|

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ms‡hvRbx- 14/24 VISIT REPORT

1. PERSONAL DETAILS:

NAME: PIN: LEVEL :

DESIGNATION: PROGRAM: DUTY STATION:

CURRENT JOB SUMMARY

2. POST TRAVELING SUMMARY:

PURPOSE / JUSTIFICATION OF THE VISIT: 3. NAME OF THE ATTENDED PROGRAM :

TYPE OF THE PROGRAM :

VENUE OF THE PROGRAM: DURATION OF THE VISIT FROM: TO: TOTAL DAYS:

DETAILS OF EXPENSES

TOTAL AMOUNT: BY BRAC : BY SPONSOR :

PERSONAL (IF APPLICABLE) :

4. DO YOU CONSIDER YOUR PURPOSE OF THE VISIT HAVE BEEN ACHIEVED? :

5. WHAT ARE THE LEARNINGS FROM THE PROGRAM YOU HAVE ATTENDED? (GIVE DETAILS BELOW)

6. HOW THIS WILL MAKE A DIFFERENCE / ENRICH YOUR DAY TO DAY JOB? (GIVE DETAILS BELOW)

7. HOW BRAC WILL BE BENEFITED? (GIVE DETAILS BELOW)

8. SIGNATURE OF THE PARTICIPANT:

DATE:

9. ATTESTATION PROGRAM HEAD/ DIRECTOR DIRECTOR HUMAN RESOURCE EXECUTIVE DIRECTOR/ MANAGING

DIRECTOR

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ms‡hvRbx- 14/25 fwel¨-Znwe‡j Aš—fz©w³i Av‡e`bcÎ

eivei mwPe eª vK fwel¨-Znwej gva¨g: h_vh_ KZ…©c¶ Rbve, Avwg ..................................................................................... wcb: ............. c`we: ..................................

wcZv:.....................................................................................................................................................

cÖKí/ Kg©m~wP/ wefvM: ......................................................... Kg© ’j/ kvLv: ...................................................

GjvKv: ............................................... †Rjv: ...................................... AÂj: .........................................

eª v‡K ........................ Zvwi‡L wbqwgZ/ †mev Kgx© wn‡m‡e †hvM`vb K‡iwQ Ges .......................................... Zvwi‡L

PvKwi wbwðZ n‡q‡Q| Avgvi eZ©gvb —i/‡MÖW ............ Ges gvwmK g~j †eZb ............................................. UvKv|

Avwg eª vK fwel¨ Znwe‡ji mKj wbqg †R‡b Gi m`m¨c` Gi Rb¨ Av‡e`b KiwQ|

Avwg A½xKvi KiwQ †h, fwel¨-Znwe‡ji mKj wbqg †g‡b Pje| fwel¨-Znwe‡ji wbqgvbymv‡i Avgvi gvwmK †eZb †_‡K

D³ Znwe‡j Avgvi cÖ Ë UvKv KZ©b K‡i ivLvi Rb¨ AbygwZ cÖ vb Kijvg|

Av‡e`bKvixi ¯v¶i: ................................................................. ZvwiL: .....................................................

¯’vqx wVKvbv: ...........................................................................................................................................

mswkó ZË¡veavq‡Ki ¯v¶i: ........................................................... ZvwiL: ..............................................

bvg: ............................................................... c`we: ....................................wcb: .............................

ïaygvÎ Uªvw÷‡ì eënv‡ii Rb¨

we‡kl ªóe¨t - ‡mev Kg©x‡ì †¶‡Î wb‡qvMcÎ Ges wbqwgZ Kg©x‡ì †¶‡Î wbwðZKiYcÎ mshy³ Ki‡Z n‡e| Ab¨_vq m`m¨fyw³i Av‡e`b Am¤ú~Y© e‡j

we‡ewPZ n‡e| - bwgwb cwieZ©‡bi Rb¨ bwgwb g‡bvbqb dig eënvi Kiv hv‡e Z‡e G‡¶‡Î Kg©xi mKj ai‡bi cÖvc¨ A‡_©i bwgwb cwieZ©b n‡q hv‡e|

Av‡e`bKvix‡K fwel¨-Znwe‡j Aš—f©y³ Kiv nj|

fwel¨ Znwej b¤i: ..................................................... Aš—fz©w³i ZvwiL:................................................

Uªvw÷i bvg: ........................................................... ¯v¶i: ........................ ZvwiL: ..............................

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ms‡hvRbx- 14/26

Kg©xF‡Yi Av‡e`bcÎ

bvg ...................................................................... wcb ..................... fwel¨-Znwej b¤i ................................

c`we .................................................................. Kg©m~wP/ cÖKí/ wefvM ...........................................................

kvLv ................................................. GjvKv .................................................. AÂj .....................................

Av‡e`bK…Z F‡Yi cwigvY UvKv .............................. (K_vq ................................................................................)

g~j †eZb ................................................. †gvU †eZb ....................................................................................

FY MÖn‡Yi D‡Ïk¨ .........................................................................................................................................

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

Av‡e`bKvixi ¯v¶i: ............................................... ZvwiL ..........................

mycvwik

mswkó ZË¡veavqK :

Kg©m~wP/ wefvMxq cÖavb:

me©‡gvU F‡Yi weeiY e‡Kqv _vKzK ev bv _vKzK (wnmve wefvM c~ib Ki‡e):

F‡Yi aiY Kg©xFY fwel¨ Znwej FY (†diZ‡hvM¨/ †diZ‡hvM¨ bq) we‡klFY Ab¨vb¨ FY

me©‡gvU M„nxZ FY UvKv: UvKv: UvKv: UvKv: ZvwiL wKw¯—i cwigvY UvKv: UvKv: UvKv: UvKv: me©‡kl wKw¯— KZ©‡bi ZvwiL KwZ©Z wKw¯—i msL¨v e‡Kqv/ Aewkó UvKv: UvKv: UvKv: UvKv: Ab¨ †Kvb `vq`vwqZ¡ _vK‡j D‡jL Ki“b:

fwel¨ Znwe‡j wbR¯ `vb UvKv:

fwel¨ Znwe‡j eª v‡Ki `vb UvKv:

†gvU Rgv UvKv:

wnmve wefv‡Mi gš—e¨ I ¯v¶i: gvbem¤ú` wefv‡Mi gš—e¨ I ¯v¶i:

FY gÄywi

FY gÄywi KwgwUi Aby‡gv`b:

gÄywiK…Z FY UvKv ...............................(gvÎ ..............................................................................................)

gvwmK wKw¯— UvKv.................................(gvÎ..............................................................................................)

my‡`i nvi (evwl©K kZKiv) ................................................... wKw¯— msL¨v .......................................................

cÖ_g wKw — (gvm) ........................ (eQi) .................... †kl wKw¯— (gvm) ....................... (eQi) ........................

FY gÄywi KwgwUi ¯v¶i I ZvwiL 1. 2. 3.

we‡kl ªóe¨: - †Kvb Ae ’v‡ZB wKw —i msL¨v, cwigvY I mgq cwieZ©b Kiv hv‡e bv| Av`vqK…Z A_© cÖ_‡g Avmj cwi‡kv‡a e¨eüZ n‡e| Avm‡ji AwZwi³ A_© my wn‡m‡e MY¨ n‡e|

- 2 Kwc Av‡e`bcÎ c~iY Ki‡Z n‡e| 1 Kwc wnmve wefvM I 1 Kwc gvbem¤ú` wefv‡Mi Rb¨|

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ms‡hvRbx- 14/27 we‡kl F‡Yi Av‡e`bcÎ

bvg .................................................................................. wcb ................. fwel¨ Znwej b¤i ........................

c`we .............................................................. Kg©m~wP/ cÖKí/ wefvM ...............................................................

kvLv ......................................... GjvKv ............................................... AÂj ................................................

Av‡e`bK…Z F‡Yi cwigvY UvKv ............................. (K_vq .................................................................................)

g~j †eZb ................................................ †gvU †eZb .....................................................................................

FY MÖn‡Yi D‡Ïk¨ ..........................................................................................................................................

cÖ —vweZ wKw¯—i cwigvb: gvwmK: ................................... UvKv K‡i †gvU: ...........................wKw¯—‡Z †diZ‡hvM¨|

Av‡e`bKvixi ¯v¶i: ........................................................... ZvwiL:..........................................

mycvwik I ¯v¶i: mswkó ZË¡veavqK:


me©‡gvU F‡Yi weeiY e‡Kqv _vKzK ev bv _vKzK (wnmve wefvM c~ib Ki‡e):

F‡Yi aiY Kg©xFY fwel¨ Znwej FY (†diZ‡hvM¨/ †diZ‡hvM¨ bq) we‡klFY Ab¨vb¨ FY

me©‡gvU M„nxZ FY UvKv: UvKv: UvKv: UvKv: ZvwiL wKw¯—i cwigvY UvKv: UvKv: UvKv: UvKv: me©‡kl wKw¯— KZ©‡bi ZvwiL KwZ©Z wKw¯—i msL¨v e‡Kqv/ Aewkó UvKv: UvKv: UvKv: UvKv: Ab¨ †Kvb `vq`vwqZ¡ _vK‡j D‡jL Ki“b:

fwel¨ Znwe‡j wbR¯ `vb UvKv:


†gvU Rgv UvKv:

MÖvPzBwU UvKv:

wnmve wefv‡Mi gš—e¨ I ¯v¶i:

gvbem¤ú` wefv‡Mi gš—e¨ I ¯v¶i:

FY gÄywi


gÄywiK…Z FY UvKv .....................................(gvÎ .........................................................................................)

gvwmK wKw¯— UvKv........................................(gvÎ.........................................................................................)

my‡`i nvi (evwl©K kZKiv) .............................................. wKw¯— msL¨v .............................................................

cÖ_g wKw — (gvm) ....................... (eQi) ...................... †kl wKw¯— (gvm) .................. (eQi) ............................

FY gÄywi KwgwUi ¯v¶i I ZvwiL

1. 2. 3.

we‡kl ªóe¨: - †Kvb Ae ’v‡ZB wKw —i msL¨v, cwigvY I mgq cwieZ©b Kiv hv‡e bv| - Av`vqK…Z A_© cÖ_‡g Avmj cwi‡kv‡a e¨eüZ n‡e| Avm‡ji AwZwi³ A_© my wn‡m‡e MY¨ n‡e| - Av‡e`bcÎ 2 Kwc c~iY Ki‡Z n‡e, 1 Kwc wnmve wefvM I 1 Kwc gvbem¤ú` wefv‡Mi Rb¨|

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ms‡hvRbx- 14/28

fwel¨-Znwej †_‡K A_© D‡Ëvjb/ F‡Yi Av‡e`bcÎ

bvg .......................................................................... wcb ............... fwel¨-Znwej b¤i ..................................

c`we ............................................................. cÖKí/ Kg©m~wP/ wefvM ................................................................

kvLv ............................................ GjvKv ...................................... AÂj .....................................................

Av‡e`bK…Z D‡Ëvj‡bi/ F‡Yi cwigvY UvKv ........................ (K_vq .......................................................................)

g~j †eZb ..................................................................... †gvU †eZb ................................................................

D‡Ïk¨ ........................................................................................................................................................

cÖ —vweZ wKw¯—i cwigvb: gvwmK ........................ UvKv K‡i †gvU ................... wKw¯—‡Z †diZ‡hvM¨/ †diZ‡hvM¨ bq|

Av‡e`bKvixi ¯v¶i: ....................................................... ZvwiL: ...............................................................



me©‡gvU F‡Yi weeiY (e‡Kqv _vKzK ev bv _vKzK):

F‡Yi aiY Kgx©FY fwel¨-Znwej FY (†diZ‡hvM¨/ †diZ‡hvM¨ bq) we‡klFY Ab¨vb¨ FY

me©‡gvU M„nxZ FY UvKv: UvKv: UvKv: UvKv: ZvwiL wKw¯—i cwigvY UvKv: UvKv: UvKv: UvKv: me©‡kl wKw¯— KZ©‡bi ZvwiL KwZ©Z wKw¯—i msL¨v e‡Kqv/ Aewkó UvKv: UvKv: UvKv: UvKv: Ab¨ †Kvb `vq`vwqZ¡ _vK‡j D‡jL Ki“b: fwel¨ Znwe‡j wbR¯ `vb UvKv:


†gvU Rgv UvKv:

wnmve wefv‡Mi gš—e¨ I ¯v¶i:

gvbem¤ú` wefv‡Mi gš—e¨ I ¯v¶i:

A_© D‡Ëvjb/ FY gÄywi


gÄywiK…Z A_© D‡Ëvjb/ FY UvKv .................................... (gvÎ .......................................................................)

wKw¯—i weeiY: gvwmK wKw¯— UvKv..................................... (gvÎ........................................................................)

my‡`i nvi (evwl©K kZKiv) ............................................... wKw¯— msL¨v ...........................................................

cÖ_g wKw — (gvm) .................... (eQi) ..................... †kl wKw¯— (gvm) ....................... (eQi) ...........................


we‡kl ªóe¨: 1. gvV ch©v‡q A_© weZiY/ wKw — cwi‡kv‡ai ci Zv PjwZ wnmv‡ei gva¨‡g ZvwjKv mn cÖavb Kvh©vj‡q ’vbvš—i Ki‡Z n‡e| 2. gÄywicÎ cvIqv gvÎ H gv‡mB UvKv D‡Ëvjb Ki‡Z n‡e Ges cieZ©x gvm †_‡K wKw — KZ©b K‡i ZvwjKv mn cÖavb Kvh©vj‡q cvVv‡Z n‡e| 3. gÄywiK„Z A_© MÖnY bv Ki‡j ev evwZj Ki‡Z n‡j Zr¶bvr `iLv‡ —i gva¨‡g H gÄywicÎmn cÖavb Kvh©vj‡q wnmve wefv‡M cvVv‡Z n‡e|

4. Av‡e`bcÎ 3 Kwc c~iY Ki‡Z n‡e, 2 Kwc wnmve wefvM I 1 Kwc gvbem¤ú` wefv‡Mi Rb¨|

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ms‡hvRbx- 14/29

eª vK Kg©xi mš—vb‡ì D”Pwk¶vi Rb¨ F‡Yi Av‡e`b cÎ

bvg ................................................................................ wcb ....................... c`we ..............................................

Kg© ’j ........................................ Kg©m~wP/ cÖKí/ wefvM .............................................. fwel¨ Znwej b¤i ....................

Av‡e`bK…Z F‡Yi cwigvY UvKv.................................. (K_vq......................................................................................)

Kg©xi g~j †eZb................................................ †gvU †eZb .................................................................. cÖ —vweZ wKw —i

cwigvb: gvwmK: ....................................... UvKv K‡i †gvU: ............................ wKw —‡Z †diZ‡hvM¨|

D”P wk¶v_x© mš—v‡bi bvg: ............................................................. wk¶vMZ †hvM¨Zv (eZ©gvb) ........................................

eqm: ............................ †Kv‡m©i bvg (†hLv‡b fwZ© n‡e ev n‡q‡Q): ...............................................................................

cÖwZôv‡bi bvg I wVKvbv (†`‡k/ we‡`‡k): ....................................................................................................................

Av‡e`bKvixi ¯v¶i I ZvwiL: ............................................


wefvMxq/Kg©m~wP cÖavb:

me©‡gvU F‡Yi weeiY ( e‡Kqv _vKzK ev bv _vKzK):

F‡Yi aiY Kgx©FY fwel¨ Znwej FY (†diZ‡hvM¨/ †diZ‡hvM¨ bq) we‡klFY Ab¨vb¨ FY

me©‡gvU M„nxZ FY UvKv: UvKv: UvKv: UvKv: ZvwiL wKw —i cwigvY UvKv: UvKv: UvKv: UvKv: me©‡kl wKw — KZ©‡bi ZvwiL KwZ©Z wKw —i msL¨v e‡Kqv / Aewkó UvKv: UvKv: UvKv: UvKv: Ab¨ †Kvb `vq`vwqZ¡ _vK‡j D‡jL Ki“b: fwel¨ Znwe‡j wbR¯ `vb UvKv: fwel¨ Znwe‡j eª v‡Ki `vb UvKv: †gvU Rgv UvKv: wnmve wefv‡Mi gš—e¨ I ¯v¶i: gvbem¤ú` wefv‡Mi gš—e¨ I ¯v¶i:

FY gÄywi


gÄywiK…Z FY UvKv ........................................... (gvÎ .........................................................................................)

gvwmK wKw — UvKv.............................................. (gvÎ..........................................................................................)

my‡ì nvi (evwl©K kZKiv) ............................................................. wKw — msL¨v .....................................................

cÖ_g wKw — (gvm) ............................ (eQi) ........................... †kl wKw — (gvm) ..................... (eQi) ......................

my‡ì nvi (evwl©K kZKiv) .................................................................................................................................. FY gÄywi KwgwUi ¯v¶i I ZvwiL

1. 2. 3.

mshyw³: - wk¶v cÖwZôvb KZ…©K cÖ Ë m¤ú~Y© Li‡Pi wnmve| - B‡Zvg‡a¨ fwZ© n‡q _vK‡j, fwZ©i iwk`|

we‡kl ªóe¨: - Av`vqK…Z A_© cÖ_‡g Avmj cwi‡kv‡a eëüZ n‡e| Avm‡ji AwZwi³ A_© my wn‡m‡e MY¨ n‡e| - Av‡e`bcÎ 2 Kwc c~iY Ki‡Z n‡e, 1 Kwc wnmve wefvM I 1 Kwc gvbem¤ú` wefv‡Mi Rb¨|

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ms‡hvRbx- 14/30 †gvUiMvox µ‡qi Rb¨ Av‡e`bcÎ

bvg:........................................................................ wcb:.................... c`we:........................................................

Kg© ’j: ......................................... Kg©m~wP/ cÖKí/ wefvM:........................................ fwel¨ Znwej b¤i: .....................

Av‡e`bK…Z F‡Yi cwigvY (UvKv):........................... (K_vq:.................................................................................gvÎ)

Kg©xi g~j †eZb: ............................................................. †gvU †eZb: .....................................................................

cÖ —vweZ wKw —i cwigvb: gvwmK ..................................... UvKv K‡i †gvU: ........................................... wKw —‡Z †diZ†hvM¨|

Mvoxi †gvU g~j¨ (UvKv): ....................................... (K_vq:................................................................................. gvÎ)

Mvoxi aiY: Kvi/ Rxc/ Ab¨vb¨ (wUK wPý w`‡Z n‡e Ges g‡Wj D‡jL Ki‡Z n‡e): ...............................................................

Av‡e`bKvixi ¯v¶i I ZvwiL: ..............................................

mycvwik I ¯v¶i:

mswkó ZË¡veavqK:

wefvMxq/ Kg©m~wP cÖavb:

me©‡gvU F‡Yi weeiY (e‡Kqv _vKzK ev bv _vKzK):

F‡Yi aiY Kg©x FY fwel¨ Znwej FY (†diZ †hvM¨/ †diZ †hvM¨ bq)

we‡kl FY Ab¨vb¨ FY

me©‡gvU M„nxZ FY UvKv: UvKv: UvKv: UvKv: ZvwiL wKw —i cwigvb UvKv: UvKv: UvKv: UvKv: me©‡kl wKw — KZ©‡bi ZvwiL KwZ©Z wKw —i msL¨v e‡Kqv/ Aewkó UvKv: UvKv: UvKv: UvKv: Ab¨ †Kvb `vq`vwqZ¡ _vK‡j D‡jL Ki“b:

fwel¨ Znwe‡j wbR¯ `vb: UvKv:

fwel¨-Znwe‡j eª v‡Ki `vb: UvKv:

‡gvU Rgv: UvKv:

wnmve wefv‡Mi gš—e¨ I ¯v¶i: gvbem¤ú` wefv‡Mi gš—e¨ I ¯v¶i:

FY gÄywi


gÄywiK…Z FY UvKv ........................................... (gvÎ ........................................................................................)

gvwmK wKw — UvKv.............................................. (gvÎ.........................................................................................)

wKw — msL¨v ............................................ cÖ_g wKw — .................................... †kl wKw — ........................................ (gvm) (eQi) (gvm) (eQi) my‡`i nvi (evwl©K kZKiv) ..................................................................................................................................

FY gÄywi KwgwUi ¯v¶i I ZvwiL 1.

2. 3.

we. ª. - Av`vqK…Z A_© cÖ_‡g Avmj cwi‡kv‡a e¨eüZ n‡e| Avm‡ji AwZwi³ A_© my wn‡m‡e MY¨ n‡e| - Av‡e`bcÎ 2 Kwc c~iY Ki‡Z n‡e, 1 Kwc wnmve wefvM I 1 Kwc gvbem¤ú` wefv‡Mi Rb¨|

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ms‡hvRbx- 14/31 Kg©x Kj¨vY Znwej

eivei mfvcwZ, Kgx© Kj¨vY Znwej

welq: Kj¨vY Znwej †_‡K Aby vb cÖ vb cÖm‡½|

Rbve, Avwg: ...................................................................................... wcb: ................. c`we: ...................................

Kg©m~wP/ wefvM: ............................... kvLv: ................................................ GjvKv: ..........................................

AÂj: ....................................... †hvM`v‡bi ZvwiL: ....................†eZb (UvKv): .................................... Kgx©Kj¨vY

Znwej †_‡K Avgvi wb‡Ri/ .......................................... wPwKrmvi Rb¨ mvnvh¨ ¯iƒc ............................. UvKv (K_vq

...................................................................... UvKv) Aby‡gv`‡bi Rb¨ Av‡e`b KiwQ|

Amy ’Zv/ wPwKrmvi weeiY: .................................................................................................................................

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

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

Amy ’Zv/ `~N©©Ubv Aby‡bv‡gvw`Z QzwU‡Z _vKv Kvjxb N‡U‡Q: nu v / bv (wUKwPý w`b)

‡ivMxi bvg (wbR e¨wZZ): ......................................................................eqm:................. m¤ú©K..........................

nvmcvZv‡ji bvg I ’vb: ..................................................................................................................................

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

mswkó wPwKrm‡Ki bvg: ........................................................... wPwKrmvi mgqKvj: ............................. ZvwiL †_‡K ........................... ZvwiL ch©š—| ewY©Z wPwKrmvi †¶‡Î QzwU AwR©Z/ we‡kl Aby‡gv`‡b (m‡eZ‡b/ webv‡eZ‡b) gÄyi Kiv n‡q‡Q ......................................... w`b|

e‡Kqv F‡Yi weeiY (hw` _v‡K): 1. UvKvi cwigvY: ..................................... Aby‡gv`b Gi ZvwiL..................... F‡Yi weeiY: ................................... 2. UvKvi cwigvY: ..................................... Aby‡gv`b Gi ZvwiL..................... F‡Yi weeiY: ................................... 3. UvKvi cwigvY: ......................................Aby‡gv`b Gi ZvwiL.................... F‡Yi weeiY: ....................................

c~‡e© Kj¨vY Znwe‡ji mvnvh¨ MÖn‡Yi weeiY: 1. UvKvi cwigvY: ......................................... Aby‡gv`b Gi ZvwiL.................... Aby v‡bi weeiY: ............................ 2. UvKvi cwigvY: ......................................... Aby‡gv`b Gi ZvwiL.................... Aby v‡bi weeiY: ............................ 3. UvKvi cwigvY: ......................................... Aby‡gv`b Gi ZvwiL.................... Aby v‡bi weeiY: ...........................

Ave‡`bKvixi ¯v¶i: ........................................................................ ZvwiL:.................................................... mycvwikKvix mswkó ZË¡veavq‡Ki gš—e¨:

¯v¶i: ........................................................ ZvwiL:........................................... wcb: ...............................

bvg:......................................................................... c`we:...................................................................... Kg©m~wP cÖavb/ cwiPvj‡Ki gš—e¨:

¯v¶i: ..................................................................... ZvwiL:.....................................................................

Øv`k

Aa¨vq

165

wnmve wefvM KZ©©„K c~iYxq

gvwmK †gvU †eZb

UvKv:

fwel¨ Znwe‡j wbR¯ `vb

UvKv:

fwel¨ Znwe‡j eª v‡Ki `vb

UvKv:

†gvU Rgv

UvKv:

cÖK…Z wej (UvKv):

wnmve wefv‡Mi gš—e¨: ¯v¶i:..........................................................................ZvwiL: .................................................................

gvbem¤ú` wefvM KZ©©„K c~iYxq

gvbem¤ú` wefv‡Mi gš—e¨:

¯v¶i:..............................................................................ZvwiL: ...............................................................

gÄywi

Avcbv‡K Kgx© Kj¨vY Znwej †_‡K Aby vb wn‡m‡e ...................................... UvKv (K_vq .......................................... ..............................................UvKv) Aby‡gv`b Kiv nÕj|

Aby‡gv`bKvixi ¯v¶i I ZvwiL Kg©x Kj¨vY Znwej KwgwUi c‡¶ gvbem¤ú` wefvM -

¯v¶i:................................................................................ZvwiL: ............................................................

we‡kl `ªóe¨: `iLv‡ —i mv‡_ mv`v KvM‡R we —vwiZ weeiY, Li‡Pi wnmve I cÖgvYcÎ (g~j wej fvDPvi) mshy³ Ki‡Z n‡e| d‡UvKwc MÖnb‡hvM¨ bq|

Øv`k

Aa¨vq

166

ms‡hvRbx- 14/32

‡gvevBj ‡dvb/ SIM µ‡qi Pvwn`vcÎ Avwg: ...................................................................................... wcb:.............. —i .........................................

c`we: .................................... Kg© ’j: ..................... cÖKí/ wefvM: ...................... fwel¨-Znwej bs: ..................

1. †gvevBj †dv‡bi myweavw`/ aiY (cª‡hvR¨ †¶‡Î wUK () wPý w`b): K. †cv÷ †cBW

L. wcÖ-‡cBW

M. †h †Kvb K¤úvbx/ Ab¨vb¨

........................... (wbw ©ó K‡i wjLyb)

2. †gvevBj †Uwj‡dvb/ SIM Pvwn`vi KviY: 3. Kg©xi ¯v¶i ..................... ZvwiL: .......................

4. mswkó ZË¡veavq‡Ki mycvwik: 5. cwiPvjK/ Dc-wbe©vnx cwiPvj‡Ki Aby‡gv`‡bi ¯v¶i:

†Uwj‡dvb wefv‡Mi Ask

‡gvevBj †dvb b¤i: ....................................................... ‡gvevBj †dv‡bi UvBc: .....................................................

‡gvevBj †dv‡bi bvg: ..................................................... µwgK bs: .....................................................................

PvR©v‡ii bvg: ................................................................ µwgK bs: ....................................................................

Ab¨vb¨ LyPiv hš¿vs‡ki bvg: .................................................................................................................................

†gvevBj †Uwj‡dvb †mU µ‡qi Rb¨ my gy³ F‡Yi Av‡e`b cÎ (†gvevBj †dvb e¨env‡ii AbygwZ cvIqvi ci F‡Yi Rb¨ Av‡e`b Kiv hv‡e)

Av‡e`bK…Z F‡Yi cwigvY UvKv: ...................................... ( K_vq: .............................................................................)

F‡Yi wKw —i msL¨v: ............................................. gvwmK wKw —i UvKv: ........................................................................

Av‡e`bKvixi ¯v¶i: ............................................... ZvwiL: .......................................

mycvwikKvix: ZË¡veavq‡Ki ¯v¶i:

ZvwiL:

gvbem¤ú` wefvM/ wnmve wefv‡Mi e¨env‡ii Rb¨

BwZc~‡e© Giƒc FY MÖnY K‡i‡Q wK? (cª‡hvR¨ †¶‡Î wUK wPý ()w`b):

n uv: / bv:

hw` K‡i _v‡K: UvKv .............................................

ZvwiL ..........................................

gvbem¤ú` wefvM: wnmve wefvM:

FY gÄywi

FY gÄywi KwgwUi Aby‡gv`b: gÄywiK…Z F‡Yi UvKv: .....................................................

(................................................................... UvKv gvÎ) gvwmK wKw —i UvKv: ..................................................

(............................................................ UvKv gvÎ)

wKw — msL¨v ................................... cÖ_g wKw — ....................................... †kl wKw — ............................................ (gvm) (eQi) (gvm) (eQi)


1| †Kvb Ae ’v‡ZB wKw —i msL¨v, cwigvY I mgq cwieZ©b Kiv hv‡e bv| ‡gvevBj ‡Uwj‡dvb/SIM µ‡qi Av‡e`b c‡Îi Aby‡gvw`Z Kwc GZØm‡½ mshy³ Ki‡Z n‡e|

2| Av‡e`b c‡Îi `yB Kwc c~iY Ki‡Z n‡e, FY gÄy‡ii ci 1g Kwc gvbem¤ú` wefv‡M Ges 2q Kwc wnmve wefv‡M msiw¶Z _vK‡e |

Øv`k

Aa¨vq

167

ms‡hvRbx- 14/33 QywUi Av‡e`bcÎ

(cÖavb Kvh©vj‡qi †¶‡Î cÖ‡hvR¨) ZvwiL: ..........................

cÖwZ .................................................................

Av‡e`bKvixi bvg ................................................................................................. wcb ............................

Avwg ...................................... Zvwi‡L/ ZvwiL †_‡K ................................. ZvwiL ch©š— ‡gvU ..........................

w`‡bi QywU gÄyi Kivi mwebq Av‡e`b Rvbvw”Q |

Aa©wè‡mi QywU n‡j wUKwPý ( ) w`b | mKvj weKvj

QywUi KviY .............................................................................................................................................

QywU‡Z _vKvKvjxb wVKvbv

............................................................. .............................................................................. Av‡e`bKvixi ¯v¶i

.............................................................................. cèx: ......................................................

.............................................................................. Kg© ’j: ....................................................

wefvM/ Kg©m~wP: ..........................................

gvbem¤ú` wefvM KZ„©K c~iYxq ‡Uwj‡dvb b¤i (ewa©Z)/†gvevBj b¤i: ..............

................................................................ ZvwiL ch©š—

Aewkó AwR©Z QywU ................................................. w`b

..................... w`‡bi QywU m‡eZ‡b/ webv †eZ‡b

gÄyi Kiv nj |

.............................................................................. ............................................................... ¯v¶i I ZvwiL Aby‡gv`bKvixi ¯v¶i I ZvwiL

QywU cwiewZ©Z n‡j wb‡æi Ask c~iY Ki‡Z n‡e

‡hvM`v‡bi cÖK…Z ZvwiL ........................... †hvM`vb Aby‡gvw`Z QywUi Av‡M/ c‡i n‡j KviY ...................................

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

............................................................. ..................................................... †hvM`vbKvix Kg©xi ¯v¶i I ZvwiL Aby‡gv`bKvixi ¯v¶i I ZvwiL

we: ª: - Aby‡gvw`Z QywUi Av‡M ev c‡i †hvM`vb n‡j Aby‡gv`bKvixi ¯v¶i wb‡Z n‡e | - m½‡iva QywUi †¶‡Î GB Av‡e`bcÎ eëüZ n‡e Ges wPwKrm‡Ki eë ’vcÎ Rgv w`‡Z n‡e| †hvM`v‡bi mgq Aby‡gv`bKvixi ¯v¶i I

wdU‡bm mvwU©wd‡KU Rgv`vb Avek¨K|

Øv`k

Aa¨vq

168

ms‡hvRbx- 14/34 QywUi Av‡e`bcÎ

(gvV Kvh©vj‡qi †¶‡Î cÖ‡hvR¨)

ZvwiL: ................................

cÖwZ ..................................................................

Av‡e`bKvixi bvg ................................................................................................wcb................................

Avwg ........................................ Zvwi‡L/ ZvwiL †_‡K......................................ZvwiL ch©š— ‡gvU ...................... w`‡bi QywU gÄyi Kivi mwebq Av‡e`b Rvbvw”Q | QywUi KviY ..............................................................................................................................................

QywU‡Z _vKvKvjxb wVKvbv

............................................................... .............................................................................. Av‡e`bKvixi ¯v¶i

.............................................................................. cèx .............................................................

.............................................................................. Kg© ’j ...........................................................

wefvM/ Kg©m~wP ...............................................

†gvevBj b¤i:.................................................

wnmvei¶K KZ„©K c~iYxq

.............................................................. ZvwiL ch©š—

Aewkó AwR©Z QywU ................................................. w`b

................... w`‡bi QywU m‡eZ‡b/ webv †eZ‡b

gÄyi Kiv nj |

..................................................................... ........................................................ ¯v¶i I ZvwiL Aby‡gv`bKvixi ¯v¶i I ZvwiL

QywU cwiewZ©Z n‡j wb‡æi Ask c~iY Ki‡Z n‡e

†hvM`v‡bi cÖK…Z ZvwiL ......................................... †hvM`vb Aby‡gvw`Z QywUi Av‡M/ c‡i n‡j KviY

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

............................................................. .................................................................. †hvM`vbKvix Kg©xi ¯v¶i I ZvwiL Aby‡gv`bKvixi ¯v¶i I ZvwiL

we: ª: - Aby‡gvw`Z QywUi Av‡M ev c‡i †hvM`vb n‡j Aby‡gv`bKvixi ¯v¶i wb‡Z n‡e | - m½‡iva QywUi †¶‡Î GB Av‡e`bcÎ eëüZ n‡e Ges wPwKrm‡Ki eë ’vcÎ Rgv w`‡Z n‡e| †hvM`v‡bi mgq Aby‡gv`bKvixi ¯v¶i I

wdU‡bm mvwU©wd‡KU Rgv`vb Avek¨K|

Øv`k

Aa¨vq

169

ms‡hvRbx- 14/35

`yN©UbvRwbZ QywUi Av‡e`b

cÖwZ: ..................................................... ZvwiL: ...............................

Av‡e`bKvixi bvg: .......................................................... wcb: .......................c`we: ...............................................

Kg©m~wP/ wefvM: ............................................................................... kvLv: .............................................................

GjvKv: ....................................................................... AÂj: ..............................................................................

eª v‡K †hvM`v‡bi ZvwiL: .................................... eZ©gvb Kg©m~wP‡Z †hvM`v‡bi ZvwiL: .....................................................

`yN©Ubv/ wPwKrmvi weeiY: ........................................................................................................................................

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

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

mswkó wPwKrm‡Ki bvg:...........................................................................................................................................

fwZ©K…Z nvmcvZvj/ wPwKrmv †K‡›`ªi bvg I c~Y© wVKvbv: ..................................................................................................

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

`yN©©Ubv Aby‡bv‡gvw`Z QzwU‡Z _vKvKvjxb N‡U‡Q: nu v / bv (wUKwPý w`b)

Kg©x Kj¨vY Znwej †_‡K `yN©UbvRwbZ Kvi‡Y Aby vb †bqv n‡q‡Q : nu v / bv (wUKwPý w`b)

Av‡e`bK…Z QywUi weeiY: ............................ZvwiL †_‡K.....................................ZvwiL ch©š— ‡gvU ............... Kvh©wèm|

c~‡e© `yN©UbvRwbZ QywU †fvM K‡i _vK‡j Zvi weeiY :

(1) ......................................... †_‡K ...................................... ZvwiL ch©š— †gvU.....................w`b m‡eZ‡b/ webv‡eZ‡b|

(2) .......................................... †_‡K .................................... ZvwiL ch©š— †gvU.....................w`b m‡eZ‡b/ webv‡eZ‡b|

............................................................. Av‡e`bKvixi ¯v¶i

QywU‡Z _vKvKvjxb wVKvbv: ........................................................................................................................................

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

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

AwR©Z QywU (QywU‡Z hvIqvi c~e© ch©š—): .............w`b| ............................................................ wnmve wefvM / gvbem¤ú` wefvM

mycvwikKvix: mswkó ZË¡veavq‡Ki gš—e¨:

¯v¶i:...................................................ZvwiL:.................................................. wcb:................................. bvg:.....................................................................................c`we: .......................................................... Kg©m~wP cÖavb/ mn‡hvMx cwiPvjK

[¯v¶i: ..................................... ZvwiL: .................................. bvg: .......................................................... Aby‡gv`bKvix: cÖ_g ZË¡veavqK/ cwiPvjK/ Dc-wbe©vnx cwiPvjK:

........ Kvh©wèm wPwKrmv QywU wn‡m‡e AwR©Z / ........Kvh©wèm m‡eZ‡b ... /........ Kvh©wèm webv‡eZ‡b QywU gÄyi Kiv nj|

¯v¶i: ....................................................... ZvwiL: ................................

Øv`k

Aa¨vq

170

ewa©Z QywU (we‡kl Kvi‡Y QywU ewa©Z Kivi cÖ‡qvR‡b c~e©vby‡gvw`Z QywU †kl nIhvi c~‡e©B GB Ask c~iY Ki‡Z n‡e)

ewa©Z QywUi weeiY: .................................ZvwiL †_‡K....................................ZvwiL ch©š— ‡gvU ............. Kvh©wèm|

Av‡e`bKvixi ¯v¶i: ...................................................................ZvwiL:.............................................................

mycvwikKvix: mswkó ZË¡veavq‡Ki gš—e¨:

¯v¶i:.............................................................. ZvwiL:............................................ wcb:..................................

bvg:..................................................................................c`we:..................................................................... Kg©m~wP cÖavb/ mn‡hvMx cwiPvj‡Ki gš—e¨:

[

¯v¶i: .......................... ZvwiL: ......................... bvg: ..............................................................................

Aby‡gv`bKvix: mswkó ZË¡veavqK/ cwiPvjK/ Dc-wbe©vnx cwiPvjK:

............................. Kvh©wèm `yN©UbvRwbZ QywU wn‡m‡e AwR©Z / m‡eZ‡b / webv‡eZ‡b gÄyi Kiv nj|

¯v¶i: ........................................................................ZvwiL: .................................................................

QywU‡k‡l Kv‡R †hvM`v‡bi cÖwZ‡e`b

QywU Abyhvqx †hvM`v‡bi ZvwiL: ................................................. †hvM`v‡bi cÖK…Z ZvwiL: ..........................................

‡hvM`vb †ìx‡Z n‡j KviY: ...................................................................................................................................

‡hvM`vbKvix Kgx©i ¯v¶i I ZvwiL mswkó ZË¡veavq‡Ki ¯v¶i I ZvwiL

mshyw³ t - wPwKrm‡Ki eë ’vcÎ I mvwU©wd‡KU (‡h wPwKrm‡Ki Aax‡b wPwKrmviZ)

- mv`v KvM‡R we —vwiZ weeiY D‡jL Ki‡Z n‡e|

- Kg©x †hvM`v‡bi mgq ZË¡veavq‡Ki ¯v¶i Avek¨K|

- QywU‡Z hvIqvi c~‡e© Av‡e`b c‡Îi d‡UvKwc I QywU †_‡K wd‡i G‡m Av‡e`b c‡Îi g~j Kwc gvbem¤ú` wefv‡M cvVv‡Z n‡e |

Øv`k

Aa¨vq

171

ms‡hvRbx- 14/36 gvZ…Z¡RwbZ/ wcZ…Z¡RwbZ QywUi Av‡e`bcÎ

ZvwiL: ...........................................

cÖwZ: ............................................................................................

Av‡e`bKvixi bvg: ..................................................................... wcb: ............... c`we: .............................

Kg©m~wP/ wefvM: ........................................................... kvLv: ....................................................

GjvKv: ...................................................................... AÂj: ...................................................

wbqwgZ Kg©x/†mev wn‡m‡e PvKwi‡Z †hvM`v‡bi ZvwiL ...................................

Avwg wbwðZK…Z/ wk¶vbwek/ †mev Kg©x wn‡m‡e ..................... ZvwiL †_‡K ........................ ZvwiL ch©š— †gvU ..........

w`‡bi QywU m‡eZ‡b / webv‡eZ‡b gÄyi Kivi Rb¨ Av‡e`b KiwQ|

QywU Abyhvqx †hvM`v‡bi ZvwiL: ........................................

mš—vb Rb¥`v‡bi m¤¢ve¨/ `ËK MÖn‡Yi ZvwiL ........................

QzwU‡Z hvevi c~e© ch©š— Kg©xi eZ©gvb mš—vb msL¨v ................ Rb| RgR mš—vb msµvš— Z_¨ (hw` _v‡K) .......................

c~‡e© gvZ…Z¡RwbZ/ wcZ…Z¡RwbZ QywU †fvM K‡i _vK‡j Zvi weeiY :

(1) ............................... †_‡K ........................... ZvwiL ch©š— †gvU..................gvm/ w`b m‡eZ‡b/ webv‡eZ‡b|

(2) ............................... †_‡K ............................ ZvwiL ch©š— †gvU.................gvm/ w`b m‡eZ‡b/ webv‡eZ‡b|

.............................................................. Av‡e`bKvixi ¯v¶i

QywU‡Z _vKvKvjxb wVKvbv: ...........................................................................................................................

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

Aby‡gv`bKvix:

mswkó ZË¡veavqK:

¯v¶i: ....................................................... ZvwiL: .................................. wcb: ...................

bvg: .......................................................................... c`we: ..............................................................

Øv`k

Aa¨vq

172

ewa©Z QywU (we‡kl Kvi‡Y QywU ewa©Z Kivi cÖ‡qvR‡b GB Ask c~iY Ki‡Z n‡e)

Avwg ................................................... ZvwiL †_‡K ............................... ZvwiL ch©š— †gvU ........................

......................... gvm/ w`‡bi ewa©Z QywU AwR©Z / m‡eZ‡b / webv‡eZ‡b gÄyi Kivi Rb¨ Av‡e`b KiwQ|

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

Av‡e`bKvixi ¯v¶i

...............................................................ZvwiL ch©š—

Aewkó AwR©Z QywU ................................................ w`b ............................. w`‡bi QywU AwR©Z Ges

................. w`‡bi QywU m‡eZ‡b/ webv‡eZ‡b

gÄyi Kiv nj|

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

wnmve wefvM / gvbem¤ú` wefvM (cÖavb Kvh©vj‡qi †¶‡Î cÖ‡hvR¨)

QywU‡k‡l Kv‡R †hvM`v‡bi cÖwZ‡e`b

QywU Abyhvqx †hvM`v‡bi ZvwiL: .................................... ‡hvM`v‡bi cÖK…Z ZvwiL: ...............................................

‡hvM`vb †`ix‡Z n‡j KviY: .......................................................................................................................

†hvM`vbKvix Kg©xi ¯v¶i mswkó ZË¡veavq‡Ki ¯v¶i I ZvwiL we‡kl ªóe¨ : - QywU‡Z hvevi c~‡e© Kg©x‡K mswkó ZË¡veavq‡Ki Aby‡gv`b wb‡q QywUi Av‡e`bc‡Îi d‡UvKwc gvV Kvh©vj‡qi †¶‡Î mswkó Dc‡Rjv

wnmvei¶K Ges mswkó gvbem¤ú` gvV Kvh©vj‡q Rgv w`‡Z n‡e| cÖavb Kvh©vj‡qi †¶‡Î gvbem¤ú` wefv‡M Rgv w`‡Z n‡e| - QywU †_‡K G‡m †hvM`v‡bi ci QywUi Av‡e`bc‡Îi g~jKwc h_vh_fv‡e c~iY K‡i gvbem¤ú` Kvh©vjq/ gvV Kvh©vj‡q Rgv w`‡Z n‡e| - QywUi Av‡e`bcÎ gvbem¤ú` wefv‡M Rgv bv n‡j Kg©xi †eZb e„w×/ mgšq eÜ _vK‡e| Kg©x †hvM`v‡bi mgq ZË¡veavq‡Ki ¯v¶i

Avek¨K|

Aby‡gv`bKvix:

mswkó ZË¡veavqK:

¯v¶i: ................................................................. ZvwiL: ................................... wcb: ...............

bvg: ............................................................................ c`we: ............................................................

Øv`k

Aa¨vq

173

ms‡hvRbx- 14/37

c`Z¨vMcÎ

eivei

-----------------------------

welq: c`Z¨vM Rbve, Avwg wbgœ ¯v¶iKvix eª vK †_‡K c`Z¨vM Ki‡Z B”QyK| Avgvi cÖ‡qvRbxq Z_¨mg~n wb‡gœ D‡jL Kiv nj: bvg:..................................................................................wcb:..........................c`we:............................ gvZvi bvg:............................................................wcZvi bvg:................................................................... ¯¿x/ ¯vgxi bvg: .................................................................... ‡gvevBj b¤i: ............................................... wcGd b¤i: ............................. †eZb¯—i:...............Kg©m~wP/ wefvM: ............................................................. kvLv: .......................................... GjvKv: ...................................... AÂj: ............................................. ‡Rjv: ............................................ eª v‡K †hvM`v‡bi ZvwiL: ............................................... eZ©gvb Kg© ’‡j †hvM`v‡bi ZvwiL:............................. c`Z¨v‡Mi KviY:................................................................................. ........................................................................................................................................................... c`Z¨vMcÎ Rgv`v‡bi ZvwiL: .......................... m¤¢ve¨ ‡kl Kg©w`em: .......................................................... AZGe, D³ welq we‡ePbv K‡i Avgvi c`Z¨vM cÎ MÖnY Kivi Rb¨ mwebq Aby‡iva KiwQ|

¯v¶i:..................................................................... ZvwiL:...............................................

mycvwikKvix: gš—e¨: mswkó ZË¡veavqK: ¯v¶i:...........................bvg:.....................................................wcb:.........................ZvwiL:....................

Kg©m~Px cÖavb/ mn‡hvMx cwiPvjK/ cwiPvjK/ Dc-wbe©vnx cwiPvjK (cÖ‡hvR¨ †¶‡Î): ¯v¶i:..................................... wcb:........................ bvg:.......................................................................... ZvwiL:....................................................................... Aby‡gv`bKvix: ¯v¶i:.......................................................................

ZvwiL:.......................................................................

gvbem¤ú` Kg©KZ©v (gvV Kvh©vj‡qi †¶‡Î cÖ‡hvR¨): ¯v¶i:.......................................................................

bvg:..........................................................................

wcb:......................... ZvwiL:.................................

we:`ª: c`Z¨vMK…Z Kg©x ms ’v Z¨v‡Mi c~‡e© mswkó gvbem¤ú` Kvh©vj‡q msiw¶Z wbw`©ó Q‡K eª v‡K PvKzwiKvjxb mg‡qi Dci wfwË K‡i mv¶vrKvi (Exit Interview) cÖ vb Ki‡e|

GK Kwc cvm‡cvU© mvB‡Ri iw½b Qwe mshy³ Ki‡Z n‡e

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c`Z¨vMcÎ Aby‡gv`‡bi cÖvwaKvi m~Px

Kg©xi aiY —i mycvwikKvix Aby‡gv`bKvix

1g - 12Zg —i ch©š— cÖ_g ZË¡veavqK Kg©m~wP cÖavb/ mn‡hvMx cwiPvjK

13Zg - 19Zg —i cÖ_g ZË¡veavqK I

Kg©m~wP cÖavb/ mn‡hvMx cwiPvjK

cwiPvjK/ Dc-wbev©nx cwiPvjK

wk¶vbwek Kgx© I

wbqwgZ wbwðZ Kgx©

cwiPvjK I Z yaŸ© —i ----- wbe©vnx cwiPvjK/ e¨e ’vcbv cwiPvjK

14Zg —i (mggvb) ch©š— cÖ_g ZË¡veavqK cwiPvjK/ Dc-wbev©nx cwiPvjK

Pzw³wfwËK Kgx© 15Zg ev Z`yaŸ© —i (mggv‡bi) cÖ_g ZË¡veavqK I

cwiPvjK/ Dc-wbev©nx cwiPvjK wbe©vnx cwiPvjK/ e¨e ’vcbv cwiPvjK

‡mevKgx© --

cÖKí Kgx© -- cÖ_g ZË¡veavqK wØZxq ZË¡veavqK

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ms‡hvRbx- 14/38 QvocÎ (Release Order) c~iY Kivi wbqgvejx

(K) QvocÎ (Release Order) c~iY Kivi mgq †Kvb& Kjv‡g Kx wjL‡Z n‡e Zv wb‡æ eY©bv Kiv nj|

Kg©x KZ©„K c~iYxq

1. ÔbvgÕ-Gi mvg‡b `vßwiK c~Y© bvg wjL‡Z n‡e| wcb, —i, c`we, mwVKfv‡e wjL‡Z n‡e| —‡ii mvg‡b Kg©xi eZ©gvb —i wjL‡Z n‡e| wcGd b¤i mwVKfv‡e wjL‡Z n‡e|

2. Kg©m~wP/ wefv‡Mi mvg‡b †h Kg©m~wP/ wefv‡M Kg©x me©‡kl Kg©iZ wQ‡jb, †mB Kg©m~wP/ wefv‡Mi bvg wjL‡Z n‡e|

3. gvV Kvh©vj‡qi †¶‡Î kvLv, GjvKv, AÂ‡ji bv‡gi mvg‡b †h Kg© ’j †_‡K Kg©x‡K QvocÎ †`Iqv n‡q‡Q †mB Kg© ’‡ji bvg wjL‡Z n‡e|

4. Kg©xi gvZv I wcZvi bvg wjL‡Z n‡e| 5. eª v‡K †hvM`v‡bi ZvwiL `yB wWwR‡U wjL‡Z n‡e| †hgb: hw` †Kvb Kg©x 1 Rvbyqvwi 2000 Zvwi‡L eª¨v‡K †hvM`vb K‡i _v‡Kb,

Zvn‡j D³ Ni Gfv‡e c~iY Ki‡Z n‡e|

6. †h Zvwi‡L Kg©x c`Z¨vMcÎ Rgv w`‡q‡Qb †mB ZvwiLwU yB wWwR‡U wjL‡Z n‡e| ZvwiL †jLvi c×wZ 5 b¤‡ii Abyiƒc|

7. Kg©x †h ZvwiL ch©š— Awd‡m KvR K‡i‡Qb †mB ZvwiL `yB wWwR‡U wjL‡Z n‡e| ZvwiL †jLvi c×wZ 5 b¤‡ii Abyiƒc| 8. gvZ…Z¡RwbZ QywUi weeiY D‡jL Ki‡Z n‡e|

9. Kg©xi mv‡_ †hvMv‡hv‡Mi Rb¨ Kg©xi wVKvbv ‡Uwj‡dvb/ †gvevBj b¤i mn D‡jL Ki‡Z n‡e|

mswkó Awdm I wnmvei¶K KZ©„K c~iYxq

10. gvV Kvh©vj‡qi †¶‡Î Dc‡Rjv/ kvLv wnmve †KvW bs Aek¨B c~iY Ki‡Z n‡e|

11. Kg©xi c`Z¨vM/ eiLv —/ wiWvb‡WwÝ/ QuvUvB/ Aemi/ Ae¨nwZi (cÖ‡hvR¨wU‡Z wUK wPý()w`b) ZvwiL yB wWwR‡U wjL‡Z n‡e| ZvwiL †jLvi c×wZ 5 b¤‡ii Abyiƒc| GB ZvwiLwU Kg©x K‡e ch©š— Kg©iZ wQj wVK Zvi c‡ii w`b n‡e|

12. Kg©xi me©‡kl gvwmK g~j‡eZb hv wQj Zv wjL‡Z n‡e| (GjvKv/ kvLv/ cÖavb Kvh©vjq †_‡K cÖ vbK…Z) 13. me©‡kl gvwmK †gvU †eZb hv wQj Zv wjL‡Z n‡e| (GjvKv/ kvLv/ cÖavb Kvh©vjq †_‡K cÖ vbK…Z) 14. Kgx©‡K †h ZvwiL ch©š— †eZb cÖ vb Kiv n‡q‡Q †mB ZvwiL `yB wWwR‡U wjL‡Z n‡e| ZvwiL †jLvi c×wZ 5 b¤‡ii Abyiƒc| 15. Kg©xi †h gvm ch©š— wcGd KZ©b Kiv n‡q‡Q Zv wjL‡Z n‡e| †hgb: †m‡Þ¤i 2000 ch©š— hw` †Kvb Kg©xi wcGd KZ©b Kiv

n‡q _v‡K, Zvn‡j †m‡Þ¤i 2000 ch©š— wjL‡Z n‡e| 16. ‡kl Kg© w`em ch©š— Kg©xi cvIbv QywU D‡jL Ki‡Z n‡e| Kg©iZ _vKv ch©š— AwR©Z QywU †_‡K QywU Dc‡fvM we‡qvM K‡i

we‡qvMdj A‡¼ I K_vq my úó K‡i wjL‡Z n‡e| A_©vr QywUi e¨v‡jÝ hv Av‡Q Zv wjL‡Z n‡e| 17. hw` †Kvb Kgx© mivmwi Kg©m~wP mnKvix (wcG) wn‡m‡e †hvM`vb K‡i _v‡Kb Z‡e cÖ‡hvR¨ Ni c~iY Ki‡Z n‡e| 18. Kg©m~wP mnKvix wn‡m‡e †hvM`vb K‡i cieZx© mg‡q Kg©m~wP msMVK c‡` cybtwb‡qvM †c‡q _vK‡j GB Ni c~iY Ki‡Z n‡e|

ZvwiL †jLvi c×wZ 5 b¤‡ii Abyiƒc| 19. Kg©m~wP mnKvix (wcG) wn‡m‡e me©‡kl gvwmK g~j‡eZb A‡¼ wjL‡Z n‡e| (wcI wn‡m‡e wb‡qvM cvIqvi c~‡e© †h g~j †eZb

wQj Zv wjL‡Z n‡e)| 20. me©‡kl gvwmK †gvU †eZ‡bi UvKvi A¼ wjL‡Z n‡e| (wcI wn‡m‡e wb‡qvM cvIqvi c~‡e© †h g~j †eZb wQj Zv wjL‡Z n‡e|) 21. hviv Kg©m~wP mnKvix (wcG) †_‡K Kg©m~wP msMVK (wcI) c‡` DbœxZ n‡q‡Qb, Zviv Kg©m~wP mnKvix (wcG) _vKvKv‡j cÖvc¨

MÖ vPzBwU D‡Ëvjb K‡i _vK‡j Zv D‡jL Ki‡Z n‡e Ges †h gvm ch©š — MÖ vPzBwU D‡Ëvjb K‡i‡Qb †mB gv‡mi bvg A‡¼ yB wWwR‡U Ges eQi yB wWwR‡U wjL‡Z n‡e| †hgb: †Kvb Kg©x GwcÖj 1999 gvm ch©š— MÖ vPzBwU Ryb 1999 gv‡m D‡Ëvjb K‡i‡Qb| †m‡¶‡Î D³ Ni Gfv‡e c~iY Ki‡Z n‡e|

gvm eQi 04 1999

22. FY MÖnY K‡i _vK‡j Zvi weeiY D‡jL Ki‡Z n‡e| me©‡kl Kg ©xFY, me©‡kl we‡kl FY, fwel¨-Znwej FY, AmvaviY FY, AwMªg I me©‡kl †gvUi mvB‡Kj F‡Yi cwigv‡Yi wb‡P †gvU M„nxZ F‡Yi UvKv A‡¼ wjL‡Z n‡e Ges †h Zvwi‡L FY MÖnY K‡i‡Qb, †mB ZvwiL D‡jL Ki‡Z n‡e| Av`v‡qi evwK Kjv‡g †gvU M„nxZ FY †_‡K †gvU Av`vq we‡qvM K‡i wjL‡Z n‡e|

01 01 2000 w`b gvm eQi

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23. evBmvB‡Kj eve` cÖ Ë FY e‡Kqv _vK‡j ïaz e‡Kqv UvKvi cwigvY wjL‡Z n‡e|

24. Kg©x †gvUi mvB‡Kj I ey eyK eywS‡q w`‡q‡Qb wK bv Zv D‡jL Ki‡Z n‡e|

25. Kg©xi cwiPqcÎ †diZ ‡Ìqv n‡q‡Q wK bv Zv D‡jL Ki‡Z n‡e| 26. Kg©xi †gvUi mvB‡Kj FY Pzw³ evwZ‡ji Av‡e`b cÎwU Dfq c„ôv c~iY Ki‡Z n‡e| hw` Kg©x cyivZb †gvUi mvB‡Kj FY

wn‡m‡e MÖnY K‡ib †m‡¶‡Î FY Pzw³c‡Î D‡jwLZ F‡Yi cwigvb, D³ Kg©x KZ…©K FY cwi‡kv‡ai cwigvb I Awdwmqvj wK.wg. D‡jL Ki‡Z n‡e|

27. Kg©xi wbKU Ab¨ †Kvb `vq _vK‡j Zvi weeiY D‡jL Ki‡Z n‡e| Ab¨ `v‡qi cÖK…Z cwigvY msL¨v I K_vq wjL‡Z n‡e|

28. wi‡cv‡U© c„ôv msL¨v GKvwaK n‡j †gvU c„ôv msL¨v D‡jL Ki‡Z n‡e|

29. GB Ask c~i‡Yi ci Kg©x ZvwiL mn ¯v¶i Ki‡e|

mswkó ZË¡veavqK KZ©„K c~iYxq

30. Kg©x‡K fwel¨‡Z c~btwb‡qvM Kiv hv‡e wK bv Zv D‡jL K‡i mswkó ZË¡veavqK bvg, wcb, c we D‡jL K‡i ZvwiL mn ¯v¶i Ki‡Z n‡e|

31. gš—e¨ I ¯v¶i Gi Q‡K mswkó wnmvei¶K, AvÂwjK wnmvei¶K, wØZxq ZË¡veavqK/ GjvKv eë ’vcK I AvÂwjK eë ’vcK gš—e¨ mn ¯v¶i Ki‡e|

32. Kg©m~wP/ wefvMxq cÖavb ZvwiL mn ¯v¶i Ki‡e| 33. cÖavb Kvh©vj‡qi †¶‡Î wewfbœ wefvM KZ©„K c~iYxq Ask h_vh_fv‡e c~iY Ki‡Z n‡e|

(L) QvocÎ c~i‡Yi mgq j¶Yxq w`K

QvocÎ c~iY Kivi mgq we‡kl mZK©Zv Aej¤b Ki‡Z n‡e Ges wb‡æ D‡jwLZ w`K¸wj j¶¨ ivL‡Z n‡e| mvgvb¨ AmZK©Zvi d‡j we`vqx Kgx©i P~ovš— wnmve wejw¤Z n‡Z cv‡i ev Ab_©K Kvj‡¶cY n‡Z cv‡i hv KviI Kvg¨ bq| 1. c`Z¨vMc‡Î Kgx©i bvg, eª¨v‡K †hvM`v‡bi ZvwiL, wcb, —i Ges c`Z¨vMcÎ Rgv`v‡bi ZvwiL ¯úó A¶‡i D‡jL _vK‡Z n‡e|

2. †Kvb Kg©x Appointment Letter cvIqvi c~‡e© hw` c`Z¨vM K‡i Zvn‡j D³ Kg©xi †hvM`v‡bi Zvwi‡Li mv‡_ Zvi Exam. Roll No. Aek¨B D‡jL Ki‡e|

3. Qvoc‡Îi mv‡_ cvIbv †Kvb Supporting Bill †hgb- Traveling Bill/ Motor cycle bill ms‡hvRb Kiv hv‡e bv| A_©vr D³ wej¸wj mswkó Kvh©vjq †_‡K wb®úwË Ki‡Z n‡e|

4. Kg©xi Kv‡Q †Kvb cÖKvi FY e‡Kqv _vK‡j †Kvb& gvm ch©š— F‡Yi UvKv KZ©b Kiv n‡q‡Q Ges KZ UvKv e‡Kqv Av‡Q Zv Qvoc‡Î mywbw ©ófv‡e D‡jL Ki‡Z n‡e|

5. c`Z¨vMcÎ Rgv`v‡bi ZvwiL Ges Qvoc‡Î D‡jwLZ Ôc`Z¨vMcÎ Rgv`vbÕ-Gi ZvwiL GKB n‡Z n‡e| c`Z¨v‡Mi Av‡e`bc‡Î †Kvb& ZvwiL †_‡K c`Z¨vM Kvh©Ki n‡e Zv ¯úófv‡e D‡jL Ki‡Z n‡e|

6. †Kvb Kg©x c`Z¨vM Kivi ci †h gvm ch©š— Zvi wcGd KZ©b Kiv n‡q‡Q, †m gv‡mi bvg ¯úófv‡e Qvoc‡Î D‡jL Ki‡Z n‡e| †Kvb Kvi‡Y hw` GKgv‡mi wcGd Gi wnmve cieZ©x gv‡mi Accounts-Gi mv‡_ †`Lv‡Z nq Zvn‡j Qvoc‡Î Zv D‡jL Ki‡Z n‡e| †hgb- †Kvb Kg©xi †kl Kg©wèm 31 Rvbyqvwi Ges Zvi Rvbyqvwi gv‡mi †eZb †deª“qvwi gv‡m eyK Kiv n‡q‡Q, †m‡¶‡Î Qvoc‡Î D‡jL Ki‡Z n‡e †h, †deª“qvwi gv‡mi Accounts-Gi mv‡_ D³ Kg©xi Rvbyqvwi gv‡mi wcGd Gi wnmve cvVv‡bv n‡e|

7. †h mKj Kg©x F‡Yi gva¨‡g †gvUi mvB‡Kj MÖnY K‡i‡Qb, Zviv †gvUi mvB‡K‡ji gvwjKvbv cvIqvi c~‡e© hw` c`Z¨vM K‡i, Zvn‡j Qvoc‡Îi mv‡_ Aek¨B †gvUi mvB‡K‡ji FYPzw³ evwZ‡ji Av‡e`bcÎ mshy³ Ki‡Z n‡e| †gvUi mvB‡Kj FYPzw³ evwZj Kivi Rb¨ Av‡e`bc‡Î †gvUimvB‡Kj ÔAwd‡mi Kv‡R Pvjv‡bvi weei‡Y †gvU wK‡jvwgUviÕ I Ô†gvUimvB‡Kj fvZv MÖnYÕ Kjv‡gi †hvMdj wbY©q Ki‡Z n‡e|

8. c`Z¨vMKvix/ Ae¨vnwZcÖvß/ eiLv — Kg©xi Kv‡Q †Kvb `vq‡`bv _vK‡j Qvoc‡Î Zv Aek¨B ¯úófv‡e D‡jL Ki‡Z n‡e|

9. Qvoc‡Î Kg©xi c`Z¨vM/ Ae¨vnwZ/ eiLv — †hwU cÖ‡hvR¨ †mwU‡Z wUKwPý () w`‡Z n‡e|

10. Qvoc‡Î ZË¡veavq‡Ki ¯v¶‡ii ’v‡b For w`‡q ¯v¶i cÖ vb Ki‡j Zv MÖnY‡hvM¨ n‡e bv|

11. †Kvb we‡kl KviY e¨wZ‡i‡K c`Z¨vMKvix Kg©x‡K Zvi †kl Kg©wè‡mi c~‡e©i c~Y©gvm ch©š— †eZb GjvKv Kvh©vjq †_‡K cÖ vb Ki‡Z n‡e|

12. Qvoc‡Îi ms‡kvwaZ bgybv di‡gUwU eënvi Ki‡Z n‡e| Qvoc‡Îi cy‡iv‡bv di‡gU¸wj evwZj e‡j MY¨ n‡e|

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ms‡hvRbx- 14/39

QvocÎ (Release Order) (gvV Kvh©vj‡qi Rb¨ cÖ‡hvR¨)

KKgg©©xx KKZZ©© „„KK cc~~iiYYxxqq

bvg:............................................................................................................ wcb: ................ —i: ..................

c`we: ....................................................... wc.Gd b¤i: .......................Kg©m~wP/ wefvM: ......................................

kvLv: ..................................... GjvKv: ..................................... AÂj: ...........................................................

gvZvi bvg: ............................................................. wcZvi bvg: ....................................................................

eª v‡K †hvM`v‡bi ZvwiL: c`Z¨vMcÎ Rgv`v‡bi ZvwiL: K‡e ch©š— Kg©iZ wQ‡jb :

bvix Kg©xi PvKwiKvjxb mg‡qi gvZ…Z¡RwbZ QywUi weeiY:

(1) ............................. ZvwiL †_‡K ................................... ZvwiL ch©š— †gvU ................. w`b m‡eZ‡b Ges ............................. ZvwiL †_‡K ................................... ZvwiL ch©š— †gvU ........................ w`b webv‡eZ‡b|

(2) ............................. ZvwiL †_‡K ................................... ZvwiL ch©š— †gvU ................. w`b m‡eZ‡b Ges ............................ ZvwiL †_‡K .................................... ZvwiL ch©š— †gvU ........................ w`b webv‡eZ‡b|

Kg©xi wVKvbv I †Uwj‡dvb/ †gvevBj b¤i (†hvMv‡hv‡Mi Rb¨): .....................................................................................

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

mmsswwkk óó AAwwddmm II wwnnmmvvee wweeffvvMM KKZZ©© „„KK cc~~iiYYxxqq Dc‡Rjv/ kvLv wnmve †KvW bs:.......................................................... c`Z¨vM/ Aemi/ Ae¨vnwZ/ wiWvb‡WwÝ/ QuvUvB/ eiLv — Kvh©K‡ii ZvwiL (cÖÖ‡hvR¨wU‡Z wUK w b):

Awdm KZ„©K cÖ vbK…Z me©‡kl †gvU †eZb (UvKv):.................. KvVv‡gv Abyhvqx g~j †eZb ................... wPwKrmv fvZv.................

hvZvqvZ fvZv.................... cÖKí evox fvov mnvqZv (‡g‡Uªv/ i“ivj)fvZv..................... KvVv‡gv Abyhvqx ‡gvU †eZb.................

†Kvb& gvm ch©š— †eZb †`Iqv n‡q‡Q: †Kvb& gvm ch©š— wc.Gd KZ©b Kiv n‡q‡Q: ...........................

†kl Kg©w`em ch©š— cvIbv QywU: ..................................... w`b (K_vq: ...................................................................) FY MÖnY K‡i _vK‡j Zvi weeiY: (UvKv) F‡Yi cwigvY G ch©š— †gvU my MÖn‡Yi ZvwiL †gvU Av`vq me©‡kl Av`v‡qi Av`v‡qi evwK ZvwiL me©‡kl Kgx©FY ................. .................. ................. ................. ................... .................... me©‡kl we‡kl FY ................. .................. ................. ................. .................... ...................

fwel¨ Znwe‡ji FY................. .................. ................. ................. .................... ...................

Amvavib FY ................. .................. ................. ................. ................... ...................

AÂ‡ji bvg:

cÖavb Kvh©vjq MÖn‡Yi ZvwiL

Kvh©mgvavi ZvwiL ¯v¶i

Kg©m~wP

gvbem¤ú` wefvM

wnmve wefvM


w`b gvm eQi

w`b gvm eQi

w`b gvm eQi

w`b gvm eQi

w`b gvm eQi

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AwMÖg ................. .................. ................. ................. ................... .....................

me©‡kl †gvUi ................. .................. ................. ................. .................... .....................

mvB‡Kj FY

evB mvB‡K‡ji Rb¨ cÖ Ë FY e‡Kqv _vK‡j Zvi cwigvY (UvKv): ..............................................................................

†gvUi mvB‡Kj I ey eyK eywS‡q w`‡q‡Qb: nu v / bv (wUKwPý w`b)

†gvUi mvB‡Kj FY Av`v‡qi evwK _vK‡j FYPzw³ evwZ‡ji Av‡e`bcÎ mshy³ Ki‡Z n‡e |

cwiPqcÎ Rgv w`‡q‡Qb? nu v / bv (wUKwPý w`b)

‡gvevBj †dvb/ wmg †diZ †`qv n‡q‡Q? nu v / bv (wUKwPý w`b)

Kg©x Kj¨vY mÂq (hw` _v‡K) : Kg©x hw` Kg©x Kj¨vY mÂq cÖK‡íi m`m¨ n‡q _v‡K Zvi we —vwiZ Z_¨ cÖ vb Ki‡Z n‡e:

- gvwmK mÂq cÖKí wnmve b¤i................. wnmve †Lvjvi ZvwiL.....................gvwmK wKw —i cwigvY ................. me©‡gvU Rgvi cwigvY.......................

- wØ¸Y Rgv cÖK‡íi wnmve b¤i .......................... wnmve †Lvjvi ZvwiL .......................me©‡gvU Rgvi cwigvY ........................

Ab¨ †Kvb `vq _vK‡j Zvi we —vwiZ weeiY c„_Kfv‡e mshy³ K‡i †gvU UvKvi cwigvY msL¨v I K_vq D‡jL Ki“b ....................

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

wi‡cv‡U© c„ôvmsL¨v GKvwaK n‡j †gvU c„ôv msL¨v GLv‡b D‡jL Ki“b

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

Kgx©i ¯v¶i:.......................................................... ZvwiL:.................................................................

mmsswwkk óó ZZËË¡¡vveeaavvqqKK KKZZ©© „„KK cc~~iiYYxxqq

fwel¨‡Z my‡hvM m„wó n‡j Kgx©‡K c~btwb‡qvM Kiv hv‡e wK ? nu v / bv

¯v¶i:............................................................................ ZvwiL:........................................ wcb:.................... bvg:.....................................................................................c`we:...................................................................

mswkó wnmve wefvM ¯v¶i:....................... ZvwiL:.................... wcb:................ bvg:.............................................. Kg© ’j.................. wØZxq ZË¡veavqK/ GjvKv e¨e¯’vcK ¯v¶i:......................... ZvwiL:................. wcb:.................. bvg:............................................ Kg© ’j.................

Kg©m~wP/ wefvMxq cÖavb ::

¯v¶i: ...................................................................... ZvwiL: ................................................................... we‡kl ªóe¨ :

1. cvm‡cvU© AvKv‡ii Qwe mn 3 (wZb) Kwc QvocÎ c~iY Ki‡Z n‡e| 2. mswkó ZË¡veavqK m¤ú~Y© QvocÎwU h_vh_ fv‡e c~iY Kivi ci ¯v¶i K‡i mswkó Kg©m~wPi gva¨‡g gvbem¯ú` wefv‡M Rgv w`‡e| 3. Kgx© e`wj n‡j e`wj cieZx© †hvM`vbcÎ A_ev gvZ…Z¡RwbZ/ wcZ…Z¡RwbZ QywU †fvM K‡i _vK‡j QywU cieZx© †hvM`vbcÎ (c~‡e© gvbem¤ú`

wefv‡M Rgv bv w`‡j) mshy³ Ki‡Z n‡e| 4. c`Z¨vMK…Z Kg©x ms ’v Z¨v‡Mi c~‡e© mswkó gvbem¤ú` Kvh©vj‡q msiw¶Z wbw ©ó Q‡K eª v‡K PvKzwiKvjxb mg‡qi Dci wfwË K‡i

mv¶vrKvi (Exit Interview) cÖ vb Ki‡e|

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ms‡hvRbx- 14/40 eª vK

QvocÎ (Release Order)

(cÖavb Kvh©vj‡qi Rb¨ cÖ‡hvR¨)

KKggxx©© KKZZ©© „„KK cc~~iiYYxxqq

bvg: ................................................................................... wcb: ...................... —i: ..............................

c`we: .............................................. Kg©m~wP/ wefvM: .......................................... wc.Gd b¤i: ...................

gvZvi bvg: .......................................................... wcZvi bvg: ............................................................

eª v‡K †hvM`v‡bi ZvwiL: K‡e ch©š— Kg©iZ wQ‡jb: c`Z¨vMcÎ Rgv`v‡bi ZvwiL:

Kg©xi wVKvbv I †Uwj‡dvb/ ‡gvevBj b¤i (†hvMv‡hv‡Mi Rb¨): .............................................................................

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

........................................................................................................................................................... bvix Kgx©i PvKwiKvjxb mg‡qi gvZ…Z¡RwbZ QywUi weeiY:

(1) ............................. ZvwiL †_‡K ................................. ZvwiL ch©š— †gvU ................. w`b m‡eZ‡b Ges

............................. ZvwiL †_‡K ................................... ZvwiL ch©š— †gvU ....................... w`b webv‡eZ‡b|

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(Exit Interview) mv¶vrKvi cÖ vb Ki‡e|

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