Fsss Abortion Application Form-revised

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  • December 2019
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  • Words: 301
  • Pages: 3
Space for Application Number

got« - 1

cHt® ghJfh¥ò ¤ £l« kf¥ngW cjé¤ bjhif bgWtj‰fhd é©z¥ggot«. ¡fiy¥Ã‰F iy¥Ã‰F k£L«) (fU¢ÁijÎ / fU¡ 1.

Mu«g Rfhjhu ãiya¤Â‹ bga®

:

2.

Jiz Rfhjhu ãiya¤Â‹ bga®

:

3. 4. 5.

é©z¥Ã¤j nj FL«g v© gadhëæ‹ bga®

: : :

6.

fztç‹ bga®

:

7.

m. ãuªju Kftç

:

M. j‰nghija Kftç

:

8.

gadhëæ‹ taJ

:

9.

r_f ãiy

:

10.

bjhêš

SC / ST / Others

fzt‹ : kidé :

11.

FL«g tUkhd«

fzt‹

:

kidé : 12.

j‰nghija f®¥g fhy«

:

13.

f®¥g gÂÎ v©

:

14.

f®¥g« gÂÎ brŒj njÂ

:

15.

v®gh®¡f¥gL« Ãurt ehŸ

:

16.

ÏJ v¤jidahtJ f®¥g«

khj§fŸ / thu§fŸ

17.

f®¥g¤Â‹ KoÎ

:

18.

fU¢ÁijÎ Md ehŸ

:

19

fU¡fiy¥ò étu«

:

20

fU¡fiy¥ò brŒj Ïl¤Â‹ bga®

:

k‰W« C® 21 fU¢ÁijÎ / fU¡fiy¥Ã‰F Ë jhæ‹ ãiy 22. V‰bfdnt cjé¤ bjhif bgw¥g£ljh? M« våš étu« 23. f®¥Ãâ fz¡F it¤JŸs t§»æ‹ bga® k‰W« »is 24 t§» nrä¥ò fz¡F v©

fU¢ÁijÎ / fU¡fiy¥ò

kU¤Jt Kiw / k‰w it

: : M« / Ïšiy : :

25. ϤJl‹ jhŒ/nrŒ ey m£ilæ‹ efš : Ïiz¡f¥g£LŸsjh?

M« / Ïšiy

ehŸ Ïl«

é©z¥gjhuç‹ ifbah¥g« mšyJ ÏlJ if bgUéuš nuif nk‰f©l égu§fŸ rçahdit vd rh‹wë¡f¥gL»wJ.

»uhk Rfhjhu bréèaç‹ ifbah¥g« bga®: nj Ïiz¡f¥glnt©oait

1. jhŒ nrŒ ey m£ilæ‹ efš 2. cHt® ghJfh¥ò ¤ £l cW¥Ãz® m£ilæ‹ efš

mYtyf cgnahf¤Â‰F 1. t£lhu kU¤Jt mYtyU¡F é©z¥g« »il¡f¥ bg‰w njÂ

:

2. é©z¥g tçir v©

:

3. é©z¥g§fŸ KGikahf ó®¤Â brŒa¥g£LŸsjh?

:

M«/Ïšiy

4.cHt® ghJfh¥ò £l¤Â‹ Ñœ ã cjé bgw jF thŒªjtuh?

:

M«/Ïšiy

5. fhnrhiy bfhL¡f¥g£l étu§fŸ I

t§»æ‹ bga®, »is

Ii

fhnrhiy v©

Iii

fhnrhiy njÂ

Iv

bjhif %.

V

fhnrhiy gadhë¡F bfhL¡f¥g£l njÂ

Vi

gadhëæ‹ ifbah¥g« mšyJ ÏlJ if bgUéuš nuif

vii

cjéahs® / f©fhâ¥ghs® ifbah¥g« bga®:

viii

njÂ: t£lhu kU¤Jt mYtyç‹ ifbah¥g« bga®: njÂ:

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