"t. "{r. cttdtcq" qfct'tv adl }}cr{"ft qrcleQ[sr

s[dr'tat{I,

ra{ina

rla.

s-I.

r,tLelcer

adldl il.uuil r,ri adldl

[efaqt (q.g.), r,ilrct]g

tlcnEter

o{1.

qtqd/ ?oro., "t."i.{t6

"i.q

,s'I.pqatqt r{.}ar

(rtcto! rtit{l'tct?.

r,t[ils Reu:{s tadldl il.ur,il)

ctt-ti-tt-?oto

.i{tel c{l!i: (t) rlrr'lxr t

o

?

o

qi

t o/(

qliqte sctugt fdertcr+t dt.ou/ro/?oro ot

o ?/ot.

r. u[i..[cte{,

[Q.ottct"tt cu..3t/oo/?oto ott 6?tct

?Y3 /ot, nQ.qlaet,

ctit{l"pttat ott"t ttoql..

1ry atqti [d.crttct"tt cu.

srris:-A${lsqcg

rtitllacteat o rt"r u,"rl,.

t+Gd r,ti untaqt

1r1

6?tcr

grtisi

ctotcu

toeolo/

a?/i?/?ors ou.6?tq g{is:- u?q/ ro?ors/r?3x/Jr.r.

ftQ."tte?f , ctitll"tctf "tt gat"t r.,t""ta,.

qRqa:r,ttr-Icer

ailqr4t arctard

giorl 'atet

r,ti

uQcra scetq (d.cttct t rrrr "r{.-rore-reui guar{dl r,rlarr

arrrr gc
url urra{i 1}a. $xrridl u({cr{ "{t,' ?ilrataf "artu qtt{i

Xurridl qrlctr+ "{t

4tq8

lut

U?r.cr.cu.

crtRrc,er"

uln*

r+talr q.cl"tt uRqra-I

@{r{qf *dl },

eeal, 4s"0,

}"ttr,

3. ?.uo atur

{r} i,t{a

.lo('t Uqar ?[?e{ il?st?

} leII r,tldl ur[i.ufls qrNs

geqtui urd.et. r*r qlvar

.tsorn

cie{lr

orcrl(ct Glqr,rlar cia{h e'Icil, oic{la tlstr,il,

q"{

r,ti. {ctrar r'Icil {r} giordto qrGlg {€d{ i.?,oo,ooo/- toi} aQeit d atrrtl Ut{I"{l Setan ue.ua Gqaotr gatctqt{i r*rd E. ?rfq'4r Bo(^ r,u.t{t

c{lua

D.

q{

rorsell q-dla srS uttsl.i. ugr rrr

6sa erfda ortq]ell atq(4ler

.r{ eoto-tc

qfv"u{i adl aqt }}cr{laf +t{ta.ct seqt:{i wde

r

rlual l.l{cr sG{ fd+arrdt drrt{

o

r{13r.?-I

r

?t?er u?sr?dt .tcten

r,ti iuat

r4r.qt[

oGa]

qi

a

crcl-

r,trtct{ curttc{t

E.

qi l{"tt qQqtciral.

r "tt ar+t{ riqci[ qa"{l gce[ra]. 6ut t0.tll gd

i{r{ti,il.

arfvar Bon euct Lo.r.u l+t) "tdl aqt

srS sare.j g?ua{.ct e&el.

r, {rEr l'l{r

lua{dl

,{Qqtegaf.

d€II fiurqs r,uQa [t*t,{ctrzat

quatuili u4urcr'j

e{t

*

})cr{at ata[€I[ gid "rrt qtrt{c{t"

dacla stS satqqt :{t} "0{ 1t4"ft

eBe1.

eG{t Orate"u

srS sarq.tt

ct{t{

rrt} qtstt

r4tgtt oGal

<*&+f

rli l{at qRqttet"il.

rrri ll{at qRqtl rtgt't sts, r,tfrnrtaf

grt+1 r,ti. utet[Is uta-icer ]"q

t

sk]{t r,ttilcq }"<"tt adlo{l

r,r[Qsr{"u €r(tte{? urtr"j g],af u[.gai ul{rqtqa @stgt U?tor

l{|.cleetg

(r rli.

?V sact"j aB. dlt?qte dfit6ct r,ilEfRdt cttt

e)

ettcrttell

uRcrr"j dRQlrrq sfl arere{Ia. +€uQa Br,il+g uaell "{r creneer""j grS

fr

s-ltJ

(rt

r,ctl.g st

t&r1 adt.

qrer otB'ti stqc(l{rriell gat gt.u}ti qtd af utEfds

rlra-Icer 3"a

il.ct

qrqqr{i qtQ. ft{i r,u.ts"ft {qlet"{I 4a

l

eG{l rlta-Ixr }"4"u adldl r,t[Qst{lf,

ail.rat) "ttqt

i.

utqrl..

rngt srct"0 e.lcf

ui

dRa *a 'ilsa

lr+"j 'ut

.ttcncar" st3

>

urrsr?-l

r*i il{"u uQqraqral: utat mt r*rucu:{i r*rdet liata

r+t[dd

nqt[ae

e]at

l4i

audtrr'r

ct "qt cl.cttc,?t" ailvataL atel

:{r} qegra'I ui ir+"rt uRcrl rter4

qi

fd.crtcr

tltot ?V nct"j

uasre"j aru

{(n.u{2(

srS satqqr

{t[dd

I

srS,

a.}c]..

r,rlnual grral

strr r,trQe u2(srr afl]"j r*lcnuua @stgt 1ry ad. d{t?qre QRgrdcr r+lElRdt strr

currueil

uR+rr"j dRfi]cra s{l ataurlli rqrQa Cir,ilrs qae{t ":{t ctcncar""j st5

qtqql{i

tttQ.

qr

*}ti ut.ts"0 4der"0

cBrl +dl.

gfd qasre rllC3)er"t ae geculri i,uQ af i"{I mqt ruGdl lirruc] " f, at.stQ.g gaRqraqql Sa afse ila (rt ?rfcr"u) i geqr"ft r.lef qi

lrr"j ?tlet

rt?sr.?oil.

otec0e{l

o

"rrt qr
qc[- g

Rxels r,uQa

stS s6rq.qr grtc1,

sla

gfaf

qct- v ar al{tl{ tic{cif qe"0 crretrd. 6qr dltll

lim ucue"u s{qr{raf:

-

{r} g{qr{l r,ti ilrr"t uQqtl erer"r srS, ?,rfer'tal

[ir+re1s

Qsn ucue+

]ri

qr\a

Clsu qcu?ou

s{r{rfl c{}<1 Rrrrls qe

r{i

s{qt{ a{t}"j {
ill$a'j u{rqrqa [dsrgr (x uri '{) l?ror ?V sa+t"j a.l.

cert?or.E dQgtdtcr

ulqlQdt

flrr

e{cuefii +ErQa

Cir,il.rs qee{l

r,u.ts"ft rrerler"ft

qr

aiil

"{t

adl.

eu<{re[

uR"ur"j dRli]era sfl

+r*teer""j srS r{rqqr{i r,ud.

8{i

o qir{ cr{.ar afg{"u R{arcttnr. e?lrttot d al lq"u ger aur"ft ar{trrt arerlds

ga(?artc,{Qt

alvaq i. r,tcu6ell ttgt srcr"0 e8it uti sacrtql

ur{,

euauellr,tf

6scr errlda

fu'j

"+t

*z

a]set

ila

B

(rrt

cucuc?{" stS
uttcteL.

grS{i u4r[a\e qrG.0ar utttrtl

a{[a\e

g]tl gttqt{l alg{t tsfgt

"{t c{tcucq" q]ctat Botlt 6sa }}ct{{i

dsttra o](ilaeUi qrol ]stAt( ile.ur"tf atat l.ndl adl aqt }}ct{tat ar+tr etattd giotli

ct{trt etat 4(nq[q[2( EiL

etgrf.

"r+t q,tdte?{" qfqratat

* urti dqt [d.id.

[dstgt,-

1. rlrer oi8<1rt)"j eu+leta gf{

{t} ao{l<,{l r,t0gt{t s. uasra'I {r}'j rur}rt+ sf{

2.

r4rQn orB+f

+.

Qs+t qcu?ou

g{qt{t rrt}'j ruQrta

s.

Qs+r qru.?ou

s{qt{t {t} {df{a

(pHc/

cHc)'i utrtr+qa

g1{

fQottct

I g{{t4t ctst"j uruqtua

afu, - sQeet{l F,uilcet) "0 .tt. rontreoro"tt rlv xdct

{g{t

u.
rl'P'-O^*-(-u.u[0r

0.arr+s 1a.il.y

ura-Icer ar,{l<,{l

ilcttr,il

r*i

adldl Ftaqt tuu[i.) critllacra. u[a,

. .

{rrel [?c
rqfiRua

Bc+r

ufltnar{l -

- ctl{t{ - ttgt

ctrrLrr

ctEl.

u:retet{t

- cnqt ct{t r,trret*{t

ttt3...

ut1...

"tsct tt[ad(et

. . . .

?

ctl.otL:-

ra1lililua g(\err{l - cr{rq. gdsaes{l(?c
c{r{.

lisrrt q[Ust{dl -

ld,otrc0ar "ttar<,r

arttr+.

RilqsE{I. - ct:{t:{.

tstJ.rt{dl r{tct}r cucncet etl.lrat r,ttttt ot.B"tf rrri. i.:+At qQqtrgtAl (Accredited social health activists)

r{?9

l,{?g) q2tg I .,rLirt

5}{.5

,l.l"r"j .1a=

Father's/Husband's (Q.dv

qCai 4t{)

ial

Surname (r439)

Address (+t?al.rJ):House No./Road

Village (ctLt{)

& Street (q?

't/

rrLclT 91511 ,-

Taluka (cttgSl) :-

:

I)istrict tRc
:-

atarrsli qQ 5.

qtrdl [lcra],$oitl

ot.

Ctor{

at{hrt

rit<,rtOa

'i-

r,rttrtr gts 'iqe

?,

3.

Lt.

qi(tstrfl oriau{

urell $ gt uttt gr

giaal

s-I6

ilaq 8r{et?

?t?er

uttt gia<1 gftl ttaqll "4r" / "ru

[i{t

eiler"tr (Ests)

cu.cncq"

qrl

gt

},

"ri araue{i ae{I.

erlr4r"j stS sara,a a€ll.

{rrt 6rcr cr}l.{ ua.rl. urr qt0.al 0 a{ € utafl r,ug $. - crf qegl{i q'qraa e4sa urldl rqrq ] r,tl{la ttqft qo{ti. ulJI la.cta rE s]ct e-l..u,J terri r,ttd al ufar e*
tg sadl t

g]vetfl

c1+1

ori D. i .s4lsa e4ril u{t {td tte0A dtA.

at{r.,t:*€l(^:-

rrftfn

<1.ts"1"{

1$,-

Documents Require (v3{ u{tqtqal)

n n n

Ration card lCtft+ StS; Aadhar card lSiclat ilceil"{l qtt{t? stSa(l 'tsct) Phorold Proof (ct{t{ Uld c{q"{l 6r+e4t c{tcttslluilat

!

cdldl qQgt{t

r4?vet?c(I t't6t

(pHc / uHc)"i

u{tgtqa

ital uttr'i r,t]Quq1)

ac,{Ic{I ?4[Ost

{'i

Ul+tetqe ao{ldl q0gr{lar ndl r+i

ilfdaaf

r,tell

gfa]

a<,{ldl r,tQsr{ lexc

r uncy, argil u?v qesr+t eefld.ct ]r?cter? (r4ret[ q8al 4t{r,ti "{l ficrc] r,ri cra{ r,rtta ur+rgrual"{I {gruqft e}a E

$

* urro saat urll rugrr u3a 0. luf

ilRare{l qtsu

cuqui

-

q.l"t c{t} gelr qmdl ecu E.

ar{trrr:-

telor.:.

filrr

adldl r,t[0st{t"0 ndt rli

strflaf filssf'

-

lilsrf-

\=)

{r}q{dl qtdr+ cttrttc€t e{l.r'tt qagtr-I r,ri irr+t uRctttqraf qY?tct

tt?31.?

tA?u

uaste'j

l,t?U

1t2(8


Father's/Husbana's

(Qav

u[i'j

't1.4)

slal

Surname (r4gg)

Address

1Ur
House No./Road

Village (Jl.LH.)

& Street (q? "iJ

H.tc[7 9]{11 ,-

Taluka (dtgSl) :-

:

District t[tc
:-

q15t?att tr

g{1.3

ct.

q[iqte'0 Ocraf'tto{tl

r,ttttLe StS "iora

1.

?.

3.

t{.

q.i(tst{{t

qr€IIg

oriBt{{l r*ru g },

- gl rct gi
{rer 65cr crrl":{ uaarL r+rrr qrD.al. E a"fl € urc{ urg $.

- fr r,nu{[ rguda

] urrlQ xqft qcfti r,ildt (dcta rU s]ct e1cr"j uui qtd al r,tlat evttdd ?E s?cl. otear q{t{ ntl sr{Bttr"0 srdc{61 €rE u{t ctsril. A{et r,tfdl .s{lga r3r sedl I sfcrer{t o1a] ori E. I .s{tsa 4A ar{ {tl stetta dtil. csdtsa

ufdl rqu4

atflq:+el(^:-

qastedl udL-

Documents Require (v?{ u{tguef)

D D

Ration card letlt+ St51 Aadharcard Ggq"(t atQeil"0 uttt{t? stSa(l qtgct) Photo ll Proof (ct4t4 grr
n

ruGd Qeucr fl?r r{Oa qasr? cr{}'i d}B}eta ud[.

n

r{?ret?o(I ilA

-

ilA"j

r,ilutrrtqe)

{rrtt{dl ?4tct{ cttcttcrl ?rl,jt"tt ?t?rf il?SL?dtL ctd- qi .tct- u orL crur{ riqril qe"ft cl:artr,rL Gur 3

dl(i

atrc0ell fir+qs

rltlct

Qs+t

ucurar srlur{lr,il

J.l?t?Lct tt?81.?

r4?u

s{ur{t'j

l,t?U

u2L5

8:{18

aru:-

l-ather's/Husband's

(!.au q[Ai'tt]t) g-lal

Surname (r43 g)

Address (+t?.ttt):House No./Road & Street (t{? "U (cttr() Village :

District tRc
qrcl clfll

Taluka (ctl.g5-I) :-

:-

eraild 5.

:-

uR

qrr"ft [d:ra-I,uc'itr

'i.

v.rr at{lu ril<,ttjet "i.

r.,ntla sts

"tqt

?,

3.

qtdu{t ai.Bufl uug g

urelt g

l,

- $l urar ggaal Sltl ueal 8t{et? rrrq O.ur alrar lesrs; ai atc{rei[ aen. - $r rtrr giq'il sfo uoqrL "{r' / "lrr c{tcnc{" ullr+r"j st5 saria a€11. - {t?t 6r.t aqr{ tt(t?rf rrtrr rarfr.af E a"{I € utafl r,ug $. - tl r,trg:{i tqttQ.ct e4sa uldl tgttu 3 ur+lrl mqtt qr{ti r,tldl f{cra rg s}a elar"j tari uLd
i

g1lrerfl

c1a1

qi

E. R
{tl

g1qftA 14iA.

atflut:tglo|':-

srlqtfl"{l n6t:-

.;

Documents Requirc (vQ{t uuu+qrtf)

n tr

n n n

Ration card (?tatd,

StS)

Aadhar card €Aot"tl, t|.8a1."0 u{tt{t? stgo{l otsc,t) Photo Id Proof (ct{t{ glrrt q4o0 6xr"tt eta[ellr,il"tt E]'a

Rrrqr urla lgstt qcuar grlqt{ afl}+1Rxe1s uat rioi0a Qsuct I gl{lat esr.j urtuq.ua

r{?cfet?"0 tt6[

ttttr

j

r,ilrnutua)

]

{<,i[Q.a fd.eucr r

sL{tat qst"i u{tqtqa

sl{l"tt

qstat

rli

Rs'rt

udl

uGaaf

urell

g{{at .tst. fiouct

g

uas{t erfldcr rl?uet? (gr[qt{t) ott}tvQ{ qrtet urrrgrlral"{l qstugft sle E r.,ri

qi. "{l Qctctf

14?u

ttrl

elel

,

*

rrtrttl

srai

il{l rtqr u3a E.

ld.ettct{i at}et il?8t?ott crcl- s I crcl- Y at

6qr dldt crtedell Rrrrrls utla Qsn uotra"tt grlqtfl pII grqr qudl rar E.

ar+ru +iqcil ua"0 vre{tq]

a{}

ar.

ar{trrt:tE0t:-

g{{["u qsr"{l u6[ ui Rssf

sl{.tf

Rss1, -

iaf