ûÍÁÚÂßñ iv

Ø`ûÚ×Ùß ÆÙÚ×ù 60.0 ð àòÔ ãû ó× ´Ô÷ÀÙß &úÀ{$ à`è×ÛÈ <$Ìõ$<.

1. µû$÷¸ µõ$ØõÝØ`

<]$û#õÚ ´ÕÙ]æØó à$×õù× : ............................................ ãû ó× ´Ô÷ÀÙ

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Á$ç$< : ............................................ ûÜõÚ´ÕÙ]
ó×(Ø`.):..............................
ûÜ$µ÷ÀßÁÚæ×/æÙ$û× :..............................................
ùÚÂßû$÷ÀÚõ× : ..............................
÷ÀÚ&ßõÚÜæßæ× :..............................................
<Ìè× :..............................
ûÜ$.µÙß.µæ$>ñ$Á× :.............................................. (ù</ûÔ_Ùß æÚδ/&ßö$<Ø ûÚÍ<`×
à<Á]õ$/ æÚÜ×$æ$Î ûÜ$èßøù× )
à`è×ÛÈ ùÚÙø$Í : ..............................................

à×÷¸Èûõß Ù÷À ÷ÀÚù× :...............................................

ãû ó× àùÔ´õ æ} ÷ÀÚù× :..............................................

2. ó×æØ`

2.1 <]$û$Íæ ù$´×:

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2.2 <]$û$Ø ÙÚ×$û÷ÀÚ‘¥×/&ßö$ûÚõ æ} à‘æ× &{ ÷ÀÚù× :

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2.3 æÈ{Ùß ÙÚûÚù× :

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2.4 æ$Ì×$ÙÛ× ÙÚûÚù× :

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2.5 &‘Ñø$ù× : &ÛÆõ (ûÔ÷Àß.)&´$è´/ {<ÔÙß <]$û$Ø× / õùÚ à×ÚõÚæ$Ø <]$û$Ø×/&

´Ôûæ$Ø

2.6 àùÔèÜ${æ à$×õùµ×ß {ÚÆæÈ Ñ&ßõØ /{<ÔÙßæØ`<ùß/àø]æßÂ<Ø` :

 &ÈûÔÌó ù´ <×& {`.û. à‘æ× àø]$ûùÚæ/<#õßõÛ×
&Ô÷¸&ÔæÈ

i. .......................... ............... ............................. ...............................

ii. .......................... ............... ............................ ...............................

iii. ......................... ............... ............................ ...............................

2.7 ûÜø$ù àùÔèÜ${æ×ùßð µ´´ µæßÂßõܵ×ß à`õÚ ûÕÌ< àõß÷À`æÛÈ &{ å<Ôùßµèß µ<ùõß
<]$û$Ø :

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ûÍÁÚÂßñ iv {Ú ûÚðÔ à‘æ.2

2.8 <]$û$Ø äßææµ×ß/à×ÚõÚæØ`<ùßµèß/{<ÔÙßæØ`<ùßµèß/àø]æßÂ<Ø`ùßµèß µûØ

àõßõÚæ$ØÈ Ñ&ßõØ :

ó× ûÜ÷À$ùÚõ à$×õù× :
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´ÔÙß ó× ´Ô÷ÀÙ(Ø`ûÚ×Ùß) :
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Ùý$èõß ÷ÀÚù× : ..................................................................

à<Á]õ$<× : ..................................................................................

µù$ûÚ×<ÔÈ µÁßÂ× : ..................................................................................

µû$ÙÛ àùÔû$õÚæ× : ...................................................................................

{Úê ´Ô÷ÀÙ (Ø`ûÚ×Ùß) :

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à$û&Ô µèÒµÈ õõß<× :

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2.9 ûÜ<Ìöù µ´µ{×ÔÈ

ûÜ<Ìöù æÚÜ×$æ$ØæÈ ûÚ}ÚýúÀ Ñ&ßõØ :

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2.10 µûØ ´ÕÙ] æÚÜ×$æ$Îõß<× : <&Ø à<&$ù×ð 2009 2010
(Ø`.000)

´Ô_ ÑæÝóÔÈ ........................... ..............................

÷À} Ù$þ× ............................ ..............................
æßÂ× æÚÎÈ/µû$ÙÛ µûØ Ù$þ× ...........................
..............................
ý÷¸ µûØ Ù$þ× ........................... ..............................

2.11 <õßæÈ &{ <èæÛÈ 2009 2010 (Ø` '000)

&ßö$<Ø <õßæÈ …………………………

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í‘è´ <õßæÈ ...................
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ØúÀ<$èõß áû`×ÛÈ)
æ$ÙÛù ó×
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í‘è´ <èæÛÈ
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2.12 û&ÔèÚ× æÚÜ×$æ$ØæÈ ûÚ}ÚýúÀ
à÷À{&ß : ...............................................................................................
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ûÍÁÚÂßñ iv {Ú ûÚðÔ à‘æ.3

3. µ×$߬õ <]$û#õÚ×

3.1 µ×$߬õ <]$û#õÚ× ûÚ}ÚýúÀ Ñ&ßõØ

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3.2 æ}´ù$æØó×
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3.3 ÆùÚ&ß ýÙ×

ûÜ<Ìöù µ×$߬õ ´Ô_ äæõÝ<
è`{`óÔ ............ ................. ................
ûÚÍÆ ............ ................. ................
äæõÝ< ===== ======== =======

3.4 æÚÜ×$õß´æ æÚÎµÈ &`Ù`&ß´

µè$òù`èÚÙÚ &$÷À$ ùÚ´æÚδ : .................................................................
(àµûßæßÂÚõ ÷ÀÚù×)
×ùßõÜ&ÕõÜ &ÑæÚδ : .................................................................
(àµûßæßÂÚõ ÷ÀÚù×)
<$óÚí´× µ´µ{×ÔÈ æð×ÔõÝ à$ØÈþ× : ..........................................................(àµûßæßÂÚõ
÷ÀÚù×)

3.5 Øíµ×ß àùÔ´`õÚ× (àùÔ´`õÚ× ´ø]´ ûÍ&Ø à½æ$Í×/û}$õß û$Ùù à½æ$Í× à$÷ÀÛ)
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3.6 <]$û#õÚ ûÚÍ<`×

(Ø`. '000)
 ûÜ<Ìöù µ×$߬õ
´Ô_ äæõÝ<
ý`‘æÝ< ûÜ$èßøù× ý`‘æÝ< ûÜ$èßøù×
áòÈ ....................... ....................... ....................... ....................... .......................
µè$òù`èÚÙÚ ...................... ...................... ...................... ...................... ......................
×ùßõÜ&ÕõÜ ...................... ...................... ...................... ...................... ......................
<${ù ...................... ...................... ...................... ...................... ......................
µ<ùõß
&ßö$<Ø ...................... ...................... ...................... ...................... ......................
<õßæÈ
ûÕÌ< µ ...................... ...................... ...................... ...................... ......................
´µ{×ÔÈ
Ñ×÷ÀÈ ...................... ...................... ...................... ...................... ......................
àÑùÚÁߥõ ...................... ...................... ...................... ...................... ......................
à<&ßö$ ...................... ...................... ...................... ...................... ......................
&ßö$<Ø
æ$/ûÜ$èßøù×
´Ô_ äæõÝ< ...................... ...................... ...................... ...................... ......................

ó× {ÚÆæØ` àùÔû$õ× (ûÜ$èßøù àùÔû$õ×)

 æØ`ó$æØ æ$Øæ ûÜ$èßøù à<Á]õ$<× èóù× æØ à´Ôóùßù. (à$æ#õÚ× ûÍÁÚÂßð v ûÚðÔ à‘æ
7 {Ú ÷Àæß<$ à`õ.)

ûÍÁÚÂßñ iv {Ú ûÚðÔ à‘æ.4

3.7 Æ}÷ÀÛ è`ùÛ´ð àµûßæßÂÚõ ×ùßõ Ü&ÕõÜ/<${ù

ù</û$ѧ¥æØù
ùÚÂßû$÷ÀÚ Æ}÷ÀÛ Æ}ðèùßù$ Ù÷À/à_õß<`±×
à×Úõ´× &`û×ÔÈæØ`
õ Øð èùßù$ ÷ÀÚù× ´Ô÷ÀÙ (Ø`.) $ æØ &æ&ß
æØù Ù÷À

3.8 µ<ùõß &ßö$<Ø <õßæÈ

à×Úõ´× ÷À`ùð´õß Æ}÷ÀÛ µèù à`õßùÈ Æ}÷ÀÛ èõß <®ù$æ´

Æ}÷ÀÛ èõ ÷ÀÚù×
3.9 µ<}úÀûÙ :

(à) ùÚÂßû$÷ÀÚõ× &{ þ$Ñõ× :

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(à$) à÷À$Ù ùÚÂßû$÷ÀÚõ×ùß µý÷À$ {`ÎµÈ Ñ½ Ñø$ù/æÜ´× :

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(à`) µ<}úÀ ûÙµ{Ú µæ$ð& àµÙÑ æØùÔ Ùýù ûÜ´$ó×ùß :

àûù×ù µ<}úÀûÙ .......................................%

µ÷ÀßÁÛ× µ<}úÀûÙ .......................................%

ûÍÁÚÂßñ iv {Ú ûÚðÔ à‘æ.5

4.0 ´ÕÙ] ÑÁßµÙßÂó× :

&$´$ù] µ´µ{×ÔÈ <ÌÂ×æ &`Ù&ÔÈèõ Ù$þ÷À$×Úõß< <$Ìõ$ &{ þ$Ñõ$ æÙ ãûµÙßçù µ´{Ú
à´Ôó$ à`õ

Ù$þ÷À$×Úõß<× ûÚ}ÚýúÀ <$Ìõ$<ÙÚùß µ{ÙÚ<ù ѵÁßÂõ$ û{õ ûÍ÷ÀÚµÓ.

(Ø`.'000)
´Ô_ ÑæÝóÔÈ : ............................................................
÷À$×æõß<× : ..........................................................
æßÂ× æÚÎÈ {$ µû$ÙÛ µûØ Ù$þ× : ......................................
ÁÝ÷Àßø Ù$þ× : ...................................................
ÑæÝóÔÈ ´õ µû$ÙÛ &{ æßÂ× æÚÎÈ <Ùð µûØ Ù$þ× %: ........................................
 ÑæÝóÔÈ ´õ ÁÝ÷Àßø µû$ÙÚ× % : .............................................................
à$µ×$ßíù´õ ûÜõÚÙ$þ % : .............................................................
(æ$ÙÛù ) ó× µ&ß<$ àùÔû$õ× : .............................................................

5.0 à$ÌöÚæ´× &Ùæ$ ý`ÙÛÈ :

µûØ û&Ô æ$Ì×æß´õ$<×

i. ÆùÚ&ß ýÙ× x xx X
ii. æ$ùßõ$ &{þ$èÛõß<× x xx X
iii. µ÷ÀßÁÛ× à´Ô÷Ü<] þ$Ñõ× x xx X
iv. ùÚÂßû$÷Àù ø$Íõ$< x xx X
v. ùÚÂßû$÷Àù× x xx X
vi. àûù×ù µ<}úÀ$´ ûÜõÚÁõ×æß µÙ&% x xx X
vii. à$ù×ù µ<ùÔ<ð ÑæÙßû µ×÷ÀÛÈ x xx X
viii. äæõÝ æ} <®ù$æÈ x xx X
ix. ѵ÷ÀßÁ ÑùÚ´× áû×ÛÈ x xx X
x. ûÜõÚÙ$þµ×ß à$ÌöÚæ èÝóÚõ× x xx X

6.0 ãû ó× ´Ô÷ÀµÙß µæ$ùßµ÷Àß&Ú {$ ùÚ×´×ùß :

6.1 ãû ó× ´Ô÷ÀÙ (Ø`ûÚ×Ùß) :

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6.2 &{ù æ$Ù× : ..........................................................

6.3 (&{ù æ$Ù× {`Ø) à$û&Ô µèÒµÈ æ$Ù×: ..........................................................

6.4 µû$ÙÛ àùÔû$õÚæ× : ..........................................................

6.5 &Ô’æÝÈ :
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6.6 ãû ó× ´Ô÷ÀµÙß µæ$ùßµ÷Àß&Ú :

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ûÍÁÚÂßñ iv {Ú ûÚðÔ à‘æ.6

7.0 ùÚ̵÷ÀßÁ×/àùÔ´`õÚ× :

............................................................................à× Ñ&Úùß á÷ÀÚÍûõß æØù Ù÷À

Ø`.....................æ ãû ó× à×÷¸Èûõ à`è×ÛÈ æØù Ù÷À àõØ, Ñ´ÌÁù×ð û$÷Àæ <Ô ãûæÙßûù
&{ àùÔ´$ù µ{$ß ´õ ÑÁßµÙßÂó× æÚεÈ÷ÀÛ µ´´ <]$û#õÚ× ´ÕÙ] <Áµ×ùß {$
õ$æßÂóÚæ Áæ]õ$<µ×ùß ×Ôæßõ ý< õ{<ÔØ` æØ´Ô.

ùÚ̵÷ÀßÁ æØù Ù÷ÀÛ. ùÚ̵÷ÀßÁ æØù Ù÷ÀÛ.

ùÚ̵÷ÀßÁ æØù Ù÷ÀÛ.

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(ù´ &{ õùõÝØ) (ù´ &{ õùõÝØ) (ù´ &{ õùõÝØ)

÷ÀÚù×:........................... ÷ÀÚù×:...........................
÷ÀÚù×:...........................

ûÜø$ù æ$Ì×$Ùµ×ß àùÔ´`õÚ× :

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(ù´ &{ õùõÝØ)

÷ÀÚù× :......................................
 &ßö$<Ø æ$Øæ ûÜ$èßøó× èóù× æÚÍ´.

áò Ùý$÷ÀÛ à`õÚ ´Ô÷ÀÙ

(Ø`.000)
÷ÀÚù èóù

(à) û<õß<$èõ ×ÔõÝ à<´ à´Ô÷º<] µõ$è× ....................... .........................

(<$ÌÂÚæ< à`&ßõµÈùßõÝ æ} ùÚÂßû$÷Àù× .......................
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æÚÜ×$õß´æ ýÑùß û<õß<$ è`ùÛ´)
(à$) æÚÜ×$õß´æ æØÆù û<õÚù æð×ÔõÝ ........................
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(à`) ùÚÆ þ$óßò(<ÌÂ×æð æßÂ×æÚÎÈ {`Ø
ûÚÍ<`× ´õ õæßµ&ßØ` æ} &$´$ù]
õý$ èõ ×ÔõÝ ) ........................
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(à|) ó× è`õÚµ×$ß (ûÚÍ<`×ð õæßµ&ßØ` æ} <$ÌÂÚæ
ó×è`õÚ µù$ûÚ×<ÔÈ µÁßÂ× .......................
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÷À} æ$Øæ ûÜ$èßøù à<Á]õ$<× .......................
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(á) àòÔ æÙ$- ûÜ<Ìöù í‘è´ <õßæÈ ....................... .........................

(ûÔ_Ùß æÚÎµÈ æ$Ì××ð à÷À$Ù<û´óæß)
&`û×ÔÈæØ`<ùßµèß ó× &{
àùÚæÝõß µæ®æ$ÙÚù ó× ....................... ..........................
(ûÔ_Ùß æÚÎµÈ <]$û#õÚ×ð à÷À$Ù)
 (â) ÁÝ÷Àßø æÚÜ×$æ$Î ûÜ$èßøù à<Á]õ$<× ........................
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à´Ô÷º<] ùÚÆ þ$óßò×æß ý<ð ûÍ<Ìõù×
æÚδð èõ<ù ÷ÀÚù èóù x <$ÌÂÚæ &#íÔ ûÚÍ<`µ×ùß
<ÌÂ×ð à`õÚ <`ò æØù ÷ÀÚù èóù à´Ô÷Ü<] + 50% ûÜ´$ó×
ûÚÍ<`×

(Ø`.'000)

<&Ø û}´Ô <&Ø &$´$ù]

i. ÷À} ÑæÝóÔÈ ...................... ..........................

ii. ûÚÍ<`ðÔÈ ý÷¸ % ..................... ..........................
iii. ÁÝ÷Àßø ÑæÝóÔÈ à$÷À$×´ (i-ii ) ...................... ..........................
iv. à´Ô÷Ü<] ...................... .........................
v. &#íÔ æÈæØ` ÁÜ´× ...................... ..........................
vi. ýÙÁæßõÚ {$ áùßøù ...................... ..........................
vii. ´Ô_ ÑëÙ] ûÚÍ<`× ...................... ..........................
viii µ<ùõß ÑëÙ] ûÚÍ<`× ..................... ..........................
ix. ÷À$×æõß<× ( iii - viii) ...................... ..........................
x. æßÂ× æÚÎÈ {`Ø æÈ{Ùß ûÚÍ<`× ...................... ..........................
xi. ûÍû$Ùù {$ à$×õù Ñ×÷ÀÈ ...................... ..........................
xii. ÑæÝóÔÈ {$ µý÷À${`ÎÈ Ñ×÷ÀÈ ...................... ..........................
xiii. µæ®æ$ÙÛù ó× µû$ÙÛ ...................... ..........................
xiv. ´Ô_ &ßö$<Ø ûÚÍ<`× ...................... ..........................
xv. µæ®æ$ÙÛù ó× µû$ÙÛ &{ù
æßÂ× æÚÎÈ µûØ ÁÝ÷Àßø Ù$þ×
( ix - xiv) ...................... ...........................
xvi. &Ô´æ ó× ûÜõÚ´ÕÙ] ó×µû$ÙÛ ...................... ...........................
xvii. µ<ùõß æ$ÙÛù ó× µû$ÙÛ ...................... ...........................
xviii. æßÂ×ÒÈ ...................... ...........................
xix. ý÷¸ µûØ Ù$þ× ...................... ...........................
xx. ÑæÝóÔÈ ´õ ÁÝ÷Àßø Ù$þ× % ...................... ...........................
xxi. à$µ×$ßíù ûÜõÚÙ$þ % ...................... ..........................
xxii. æ$ÙÚù ó× µ&ß<$ àùÔû$õ× ....................... ..........................

<]$û#õÚ <$Ìõ$µÓ àùßõÌèõ×.

1. ãû ó×æØ`
 <]$û$Íæ ù$´× :
 æÌ´$ùßõÁ$Ù$/æ$Ì×$Ù ÙÚûÚù×ùß:
 &‘Ñø$ùµ×ß <Ìè×/&ß<þ$<× :
 ÙÚ×$û÷ÀÚ‘¥æ}/ &‘&ßö$ûÚõ ÷ÀÚù× à‘æ× à$÷ÀÛ× :
2. {ÚÆæØ`µèß /{<ÔÙßæØ`<ùßµèß/àø]æßÂ<Ø`ùßµèß ûÔ÷ÀßèÙÚæ µõ$ØõÝØ`
 &ÈûÔÌó ùÈ
 ûÔ÷ÀßèÙÚæ ÙÚûÚù×ùß
 <×&ß
 &ßöÚØ û÷ÀÚ‘¥×
 {`ú¸ùÔÈûõß à‘æ×
 {<ÔÙßæØ`/àø]æßÂ<Ø`ùßµèß µæ$ð&ß {ÚÆæÈ
 µûØ àõß÷À`æÛÈ/ àø]$ûù &Ô÷¸&ÔæÈ
 &$´$ù] ´$&Úæ à$÷À$×´

3. àùÔý÷Àß½õ &´$èÈ/ &´$èÈ <]$û$Ø µ{$ß {<ÔÙßæ$Ø <]$û$Ø<Ù µõ$ØõÝØ`

4. (ûÜ<Ìöù ÷ÀÚ×ÔóÔ<ð ýÙû| ) ûÕÌ< æÚÜ×$æ$Îõß<× (ûÜ<Ìöù <]$û$Ø<Ùð à÷À$Ù< )

 ûÜ<Ìöù <]$û#õÚµ×{Ú Ñ&ßõØ.

 û&ÔèÚ× ´ÕÙ] <$Ìõ$ <ÙÚùß Ùý$èõß µõ$ØõÝØ`
(ûÜ<Ìöù <õßæÈ<Ù µ<ùõß <®ù$æÈ)
 <]$ûص×ß µ&ß<æ &‘ç]$<
 ãû ó×æØ`µèß µûØ ó× ´Ô÷ÀÙß
 þ$óßò &{ æ$Ì××ùß Æ}÷ÀÛ è`ùÛ´ &úÀ{$ àùÔè´ù× æØù <$óÚí´× ûÍë×.

5. µ×$߬õ <]$û#õÚ×.
 <]$û#õÚ× ûÚ}ÚýúÀ Ñ&ßõØ
 ´ÔÙÚæ µõ$ØõÝØ`
 ûÚ{Ú¯´.
 ùÚÂßû$÷Àù æÚÜ×$<ÙÚ×
 ø$Íõ$<
 ×ùßõÜ &{ µ´<ÙÈ
 õ$æßÂóÚæ ѽ Ñø$ù

 æÚÜ×$õß´æ <`ò &ð{ù

 <]$û#õÚ æ}´ù$æØó× &{ ÆùÚ&ß ýÙ×
 à´Ô÷Ü<]
  þ$Ñõ×
 Ø$í] &{ ûÜ$µ÷ÀßÁÛ× à½æ$͵×{Ú àùÔ´`õÚ×.

6. µ<}úÀûÙ µõ$ØõÝØ`
 µ&ß<$µÓ/ùÚ´`<ÔµÈ <Ìè×
 µ&ß<$</ ùÚ´`<Ô´ &úÀ{$ û<õßù$ áÙßÏ´
 µ&ß<×ð/ùÚ´`<Ô´ð à÷À$Ù æØèõ {`æÚ ÆÙ
 ÑæÚóÚ× {`æÚ ûÜ´$ó×
 µý÷À${`ÎµÈ Ñ½ Ñø$ù

7. ´ÕÙ] ÑèÜ{×
 <]$û#õÚ ûÚÍ<`× &{ ´ÕÙ]æØó×
 æÚÜ×$õß´æ <&Øæ ûÔµØ$ßæöù Ù$þ÷À$×Úõß<×
 ´ÕÙ] àùÔû$õ - ÷À} õÛØ`<
- ÁÝ÷Àßø õÛØ`<
- à$µ×$ßíù ûÜõÚÙ$þ
- ó× µ&ß<$ àùÔû$õ×
- ó×/÷À$×æõß< àùÔû$õ×

 ÁÝù] Ù$þ õõß<×

( Break even point)
 àþ]ùßõØ ûÜõÚÙ$þ àùÔû$õ×
 ´ÕÙ] ûÜ<${ ûÜæ$Á×
 ù$´ ´$õÜ µÁß ûõÜ×
8. à$ÌöÚæ &$ø$ØóÛæØó× &{ ÑÂ× <Ô <]$û#õÚµ×ß üÙ÷À$×Ûõ$<×

µûØ û&Ô üÙ÷À$×Ûõ$<×

i. ÆùÚ&ß ýÙ× x xx X
ii. æ$ùßõ$ &{þ$èÛõß<× x xx X
iii. µ÷ÀßÁÛ× à´Ô÷Ü<] þ$Ñõ× x xx X
iv. ùÚÂßû$÷Àù ø$Íõ$< x xx X
v. ùÚÂßû$÷Àù× x xx X
vi. àûù×ù µ<}úÀ$´ ûÜõÚÁõ×æß µÙ& x xx X
vii. à$ù×ù µ<ùÔ<ð ÑæÙßû µ×÷ÀÛÈ x xx X
viii. <®ù$æÈ äæõÝ æÚδ x xx X
ix. ѵ÷ÀßÁ ÑùÚ´× à`è×ÛÈ x xx X
x. à$ÌöÚæ´× ûÜõÚÙ$þ àùÔû$õ× x xx X
xi. ûÚÍ<`× &{ ûÜõÚÙ$þ &úÀ{$ x xx X

9. ó× ´Ô÷ÀµÙß µæ$ùßµ÷Àß&Ú &{ ùÚ×´×ùß

 ó× ´Ô÷ÀµÙß ûÜ´$ó×
 µû$ÙÛ àùÔû$õÚæ×
 &{ù æ$Ù×
 à$û&Ô µèÒµÈ æ$Ù×
 á÷ÀÚÍûõß æ} &Ô’æÝ´
 µ<ùõß ó× µæ$ùßµ÷Àß&Ú

10. µ<ùõß µõ$ØõÝØ`

 ó×æØ`µèß à×÷¸Èûõ Ù÷À ÷ÀÚù×
 ãû ó× ´Ô÷ÀÙ àùÔ´õ æ} ÷ÀÚù×
 à`è×ÛÈ ùÚÙø$͵èß ù´

11. à`è×ÛÈ <$Ìõ$< µ×$߬õ ãû <]$û#õÚ× &úÀ{$ ´ÔÙ]æØó× æÚÎµÈ æ$Ì×× &õÝðÔ÷À$×æ
µÙ&
&$ø$ØóÛæØó× æØ õÚÃ× ×ÔõÝ×. ä× ûÜø$ù æ$Ì×$Ùµ×ß æÝò$ {$ ´ø] ûÍ´$ó <]$û$Ø
äßææ× {Ø{$ à$<Øó àùÔ´`õÚ× &úÀ{$ á÷ÀÚÍûõß æ} ×ÔõÝ×.
 àè`×ÛÈ <$Ìõ$< &úÀ{$ à$÷ÀÌÁ×
1. µû$÷¸ µõ$ØõÝØ`

ãû ó× à$×õù× : ............................................ ãû ó× ´Ô÷ÀÙ (Ø`.):..............................

Á$ç$< : ............................................ <Ìè× :..............................
÷ÀÚ&ßõÚÜæßæ× :..............................................
ùÚÂßû$÷ÀÚõ×/µ&ß<$ : ..............................
ûÜ$µ÷ÀßÁÚæ×/æÙ$û× :.............................................. à`è×ÛÈ
ùÚÙø$Í :.............................……………………….
à×÷¸Èûõ Ù÷À ÷ÀÚù× : ............................................................................................

´ÕÙ] û{&Ôæ´ àùÔ´õ æ} ÷ÀÚù× : .............................................................................................

2. ó×æØ`

2.1 <]$û$Íæ ù$´×:

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2.2 æÈ{Ùß ÙÚûÚù× :

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2.3 æ$Ì×$ÙÛ× ÙÚûÚù× :

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2.4 &‘Ñø$ù× :

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2.5 &‘Ñø$ù× : &ÛÆõ &‘ç]$</ {<ÔÙß <]$û$Ø× / õùÚ à×ÚõÚæ$Ø <]$û$Ø×/&´Ôûæ$Ø/µ<ùõß

àùÔèÜ${æ {ÚÆæÈ Ñ&ßõØ /{<ÔÙßæØ`<ùß/àø]æßÂ<Ø` :

 &ÈûÔÌó ù´ <×& {`.û. à‘æ× àø]$ûùÚæ/<#õßõÛ×
&Ô÷¸&ÔæÈ

i. .......................... ............... ............................. ...............................

ii. .......................... ............... ............................ ...............................

iii. ......................... ............... ............................ ...............................

2.6 ûÜ<Ìöù µ´µ{×ÔÈ æÚÜ×$æ$Îõß<× ( ûÜ<Ìöù µ´µ{×ÔÈ æð×ÔõÝ ûÚ}ÚýúÀ µæ® Ñ&ßõØ
&û×ùßù.)

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

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3. µ×$߬õ <]$û#õÚ×
3.1 µ×$߬õ <]$û#õÚ× ûÚ}ÚýúÀ Ñ&ßõØ×
(ûÔ{ÔóÔ æÚÎÈ µ{$ß ãûµ÷ÀßÁæ <]$û#õÚ &úÀ{$ Ùý$è`ùÛ´ð àµûßæßÂÚõ à×µèß
õ$æßÂóÚæ ûÜ<ùõ$<× ûÚ}ÚýúÀ ¶< ÷Àõßõ ûÔ÷ÀßèÙ×$ / à$×õù× µõ$ßØ$èõß à$æ$Ø×,
áÙßÏÈæØù &{$×<Ù &ß<þ$<× ÷Àæß<ùßù.)
............................................................................................................................................

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3.2 à$ØÈþ æÚÎµÈ µÙßçó×

3.3 <]$û#õÚ Ñ×÷À´

3.4 õ$æßÂóÚæ <]$û#õÚµ×ùß àµûßæßÂÚõ ûÜõÚÙ$þ

4. ó× µ&ß<$ {`æÚ×$<
(û&ÔèÚ× ´ÕÙ] æÚÜ×$æ$Íõß<×ùß, <]$û#õÚ× &{ ó×æØ`µèß àµùæÝõß à$÷À$×È û÷ÀùÈ
æØ µèù û{õ &úÀ{ùß µõ$ØõÝØ` ó× à$û&Ô µèÒµÈ {`æÚ×$< &$ø$ØóÛæØù× &úÀ{$
µ×$÷À$èùßù.)
Ø`. '000
´Ô_ ÑæÝóÔÈ .......................
µû$ÙÛ &{ æßÂ× µûØ Ù$þ× .......................
µ<ùõß à$÷À$×È .......................
ó× µ&ß<$ à$<Øó àùÔû$õ× ......................

5. µ&&ß û{&ÔæµÈ ùÚ×´×ùß {$ µæ$ùßµ÷Àß&Ú

5.1 ûÜ÷À$ù× (Ø`.) .......................
5.2 ãû ó×
(à) ûÜ´$ó× (Ø`.) .......................
(à$) &{ù æ$Ù× ........................
(à`) à$û&Ô µèÒµÈ æ$Ù× (&{ù æ$Ù× à`õÝ_<) .......................
(à|) µû$ÙÛ àùÔû$õ× .......................
(á) &Ô’æÝÈ .......................

6. ùÚ̵÷ÀßÁ×/àùÔ´`õÚ× :

............................................................................ à× Ñ&Úùß á÷ÀÚÍûõß æØù Ù÷À

Ø`.....................æ ãû ó× à×÷¸Èûõ à`è×ÛÈ æØù Ù÷À &ÇæßÂóµ×ß ùÚè´ù× ´õ µ×$ßíù$<
ý`‘æÝµÓ &{$× Ù`Ä´ð &Ô÷¸&ÔæÈ Ùý$ à`õÚ ý< &{õÚæ æØ´Ô.

ùÚ̵÷ÀßÁ æÙ$.

....................................
(ù´ &{ õùõÝØ)

÷ÀÚù×:...........................

àùÔ´õ æØù Ù÷ÀÛ.

....................................
(ù´ &{ õùõÝØ)

÷ÀÚù×:...........................

ûÜø$ù æ$Ì×$ÙÛ× àùÔ´`õÚ× :

.............................................
(ù´ &{ õùõÝØ)

÷ÀÚù× :......................................