y{ËkðkË BÞwrLkrMkÃk÷ fkuÃkkuohuþLk

MLkkLkkøkkh ¾kíkw MkÇÞ ÃkË {kxuLkwt Vku{o

¾ yhsËkhLkwt ÃkwÁt Lkk{ :
(Applicant’s name) .................................................................................................
¾ ÃkwÁ MkhLkk{wt :
(Address) .............................................................................................................. yhsËkhLkk
¾ sL{ íkkhe¾ : ............... ô{h :..... ð»ko ....... ô[kE ...... Vwx/{exh (2) Vkuxk
Birthdate : ......................... Age ........... Year .......... Height ........... Feet/Inch .............
¾ {kuçkkE÷ Lkt : ..................... E-{uE÷ :
Mobile ........................................ E-mail : ..............................................................
¾ ykurVMk ½h
Phone no (office) ......................................... (Home) ..............................................
MkÇÞÃkËLkku «fkh(9)
¾ òýfkh : ðkŠ»kf A{krMkf rºk.{krMkf {krMkf (Võík {k[o {kMk {kxu)
(Swimmer) Yearly Half Yearly Quarterly onlyfor the month march

¾ rþ¾kW MkÇÞ : 12 ð»koÚke {kuxk 12 ð»koÚke LkkLkk

(Learner) (Above 12) (Below 12)

¾ òrík (9) : ÃkwY»k /(M) yLÞ

(Gender) †e/(F) (other)

¾ MLkkLkkøkkhLkwt Lkk{ :
(Name of swimmingpool) ........................................................................................................................
fLMkuþLk {u¤ððk {kxu
¾ þk¤k / fku÷usLkk [k÷w þiûkrýf ð»koLkk rðãkÚkeo Au.
þk¤k / fku÷usLkwt Lkk{ :
School/College Name
yk[kÞoLkk Mkne/rMk¬k
Principal’s signature/stamp
For A.M.C. Employlees
¾ BÞw. f{o[kheLkwt Lkk{ :
¾kíkkLkwt Lkk{ : yuBÃ÷kuE Lkt
Department Name ................................................................................... Employlee No. ........................................
¾kíkkLkk yrÄfkheLkk Mkne/rMk¬k
Signature of H.O.D. .................................................................................
MkÇÞ ÚkðkLkk rLkÞ{ku
¾ MkÇÞÃkË {u¤ððkLkk rLkÞ{ku íkÚkk MLkkLkkøkkh{kt íkhíke ð¾íku Ãkk¤ðkLkk Mk÷k{íkeLkk rLkÞ{ku íkÚkk Ve ytøkuLke {krníke ðuçkMkkEz
WÃkh / MLkkLkkøkkhLkkt LkkuxeMk çkkuzo WÃkh ðkt[u÷ yLku Mk{su÷ Au. su {Lku çktÄLkfíkko Au.
¾ y{ËkðkË BÞwrLkrMkÃk÷ fkuÃkkuohuþLk Mkt[kr÷ík MLkkLkkøkkhLkku WÃkÞkuøk fhíkk fkuEÃký MkÇÞLku fkuEÃký LkwfþkLk Eò yÚkðk òLknkrLk
ÚkkÞ íkku íku ytøku y.BÞw.fku. yLku íkuLkk yrÄfkhe íkÚkk fku[ sðkçkËkh hnuþu Lknª. ðÄw{kt ykÚke ònuh fheyu Aeyu fu yk Vku{o{kt
¼hu÷ rðøkíkku y{khe òý yLku {kLÞíkk {wsçk ¾he Au. íku{s MktMÚkkLkk rLkÞ{ku y{kuLku çktÄLkfíkko hnuþu.
¾ fkzo VeLkk Lkkýkt Yk. 100/- MkÇÞ VeLke MkkÚku rMkðef MkuLxh Ãkh [wfððkLkk hnuþu.
¾ yhS Vku{oLke MkkÚku yuf Vkuxku (ÃkkMkÃkkuxo MkkEÍ)Lkku y÷økÚke ÷kððkLkku hnuþu. (WÃkh ÷økkzu÷ Vkuxku WÃkhktík)
ðk÷eLke Mkne : yhsËkhLke Mkne : ..................................
Parents/Gaurdians ............................................................. Applicant’s Signature ...................................................

(18 ð»koÚke Lke[uLkk yhsËkh {kxu) íkkhe¾ :...........................................

(Below 18 Year)
MLkkLkkøkkhLkk yrÄfkhe íkÚkk fku[Lke Mkne :.......................
....................................... MLkkLkkøkkhLkk yrÄfkhe/fku[Lkwt Lkk{ :............................
Lkkýkt ÷uLkkhLke Mkne / Mkeðef MkuLxhLkku rMk¬ku MLkkLkkøkkhLkk yrÄfkhe / fku[Lkku yuBÃ÷kuE Lkt. : ..................
‚{t{ M™t™t„th{tk òýfth ‚Útt {tuxt þe¾tW ‚Útt ƒt¤ þe¾tW ËÇÞtu™tu Mðek{ek„ ƒu[™tu Ë{Þ ™e[u {wsƒ
hnuþu.

1. òýfth ËÇÞtu™e ƒu[™tu Ë{Þ : Ëðthu :- 6 : 00 Úte 9 : 00 f÷tf

Ëtksu :- 6 : 00 Úte 7 : 30 f÷tf

2. {tuxt þe¾tW ËÇÞtu™e ƒu[™tu Ë{Þ : Ëðthu :- 9 : 15 Úte 10 : 00 f÷tf

Ëðthu :- 10 : 15 Úte 11 : 00 f÷tf
Ëtksu :- 5 : 00 Úte 5 : 45 f÷tf

3. ÷uzeÍ ËÇÞtu™tu Ë{Þ : ƒ…tuhu: 1. Úte 1.45 rþ¾tW Mºte ËÇÞtu,

,, 2.00 Úte 2.45 òýfth Mºte ËÇÞtu,
,, 3.00 Úte 3.45 rþ¾tW Mºte
,, 4.00 Úte 4.45 òýfth Mºte

4. ƒt¤ þe¾tW ËÇÞtu™e ƒu[™tu Ë{Þ : Ëðthu :- 6 : 00 Úte 6 : 45 f÷tf

Ëðthu :- 6 : 45 Úte 7 : 30 f÷tf
Ëðthu :- 7 : 30 Úte 8 : 15 f÷tf
Ëðthu :- 8 : 15 Úte 9 : 00 f÷tf

5. ƒt¤ þe¾tW ËÇÞtu™e ƒu[™tu Ë{Þ : Ëtksu :- 5 : 45 Úte 6 : 30 f÷tf

Ëtksu :- 6 : 30 Úte 7 : 15 f÷tf

™tukÄ :- ybœtJtœ Bgwrlrmvj ftuvtuohuNl mkkatje< Mltltdth Ft<tbtkk 12 J»to&e Wvhle brnjtytu btxu
leau œNtoJuj Mltltdth Wvh cvtuhlt 1 &e 5 œhBgtl rNFtW <&t òKfth cua ftgoh< Au.
1.Jeh mtJhfh Bgw.Mltltdth JtmKt
2.mhœth vxuj Bgw.Mltltdth lJhkdvwht
3.rnhtCtR Mbthf Bgw.Mltltdth ftkkfhegt
4.r¢fuxh vÈ©e smwCtR vxuj Bgw.Mltltdth Jtzs
5.¢tkkr<Jeh rJX]]jCtR vxuj Bgw.Mltltdth ytuZJ
6.MJtbe rJJuftlkkœ Bgw.Mltltdth ctdurVhœtu»t
7.r¢fuxh©e rJlw btkkfz Bgw.Mltltdth htKev
8.©e hbKCtR jÕjwCtR Bgw.Mltltdth jtj œhJtò
9.MJ.jtjCtR ActCtR vxuj Bgw.Mltltdth FtuFht

<btb Mltltdth Wvh œh dwYJthu hò hnuNu.

y.Bgw.ftuvtuohuNlle slhj ctuzolt XhtJlkk.985 <t.28/11/2018le bkkswhe&e J^thtu
ybjbtkk ytJuj Au.
y-Jdo f-Jdo
JtmKt Mltltdth FtuFht Mltltdth
Mxurzgb Mltltdth ymthJt Mltltdth
ðtzs Mltlt„th mthkdvwh Mltltdth
c-Jdo
ftkfhegt Mltltdth mhmvwh Mltltdth
rJd< jtjœhJtò Mltltdth
ytuZJ Mltltdth
ntS…wht Mltltdth
çttduVehœtuN Mltltdth
htKev Mltltdth
mtchb<e Mltltdth

mtbtLg œh fLmuNl œh mtbtLg œh fLmuNl œh mtbtLg œh fLmuNl œh

òKfth mÇgtu btxu mwra< œh
mÇg Ve
(y) Jtr»tof 3600 2500 2000 1400 1500 1000
(c) rºt btrmf
yur«j &e swl 2400 1700 1200 800 900 600
swjtR &e mÃxu 2000 1400 1100 800 800 600
ytufxtu &e rzmu 800 600 700 500 400 300
òLgw &e btao 1200 800 900 600 500 400
(f) A btrmf
yur«j &e mÃxu 3200 2200 1500 1000 1000 700
ytufxtu &e btao 1400 1000 900 600 700 500
(z) btrmf
V¾< btao 300 200 240 160 200 140
NeFtW mÇgtu btxu mwra< œh
- - - - - -
yuf btmle mºt Ve 800 600 600 400 500 340
Slhj
zwÃjefux ftzo Ve 200 200 200 200 200 200
ftzo Ve 100 100 100 100 100 100
duMx Ve (Vf< òKfth 100.00 100.00 100.00 100.00 100.00 100.00
mÇgtu btxu)
Mltltdth Ctzu 20000 - 15000 - 15000 -
htFJtle yuf rœJmle
zevtuÍex
(Vf< <hKr¢gt btxu)
Mltltdthlwk yuf rœJmlwk 20000 - 15000 - 15000
Ctzw
(Vf< <hKr¢gt btxu)
Lgwl<b rzMx[[efx MJebekkd auBveglNevbtkk «&b <&t ceò huLfbtkk ytJuj MJebhtulu Yt.501/- &e òKfth mÇglwk me ftzo ytvJtbtkk ytJNu
 Ëkfíkhe «{kýÃkºk
ykÚke nw t «{kýÃkºk ykÃkw t Au fu íkk. ........................... Lkk hku s {u
©e ................................................................... Lke þkhehef íku{s ðiËfeÞ íkÃkkMk
fhu÷ Au. su {khk ðiËfeÞ ¿kkLk «{kýu ònuh fÁt Awt fu WÃkh sýkðu÷ fkuE ÔÞÂõík{kt Lke[u sýkðu÷
yuf Ãký hkuøk {k÷w{ Ãkzíkku LkÚke {kt rLkþkLk fhu÷ hkuøk {k÷w{ Ãkzu÷ Au.

1) þhËe yÚkðk V÷w (Cold of Flu)

2) f{¤ku (Jaundice)
3) òíkeÞ hkuøk (Veneral Diseases) íkÚkk íð[kLkku hkuøk (Skin Diseases)
4) VuVMkkLkku ûkÞ (Pulmonary. T.B.)

5) {qºk hkuøk (Urinary Diseases)

6) f]r{ hkuøk (Wrom Infection)
7) {hzku (Dysentery)
8) [¬h íkÚkk ðkE (Vertigo of Hysteria)
9) ÓËÞ íkÚkk ïMkLk hkuøk (Heart & Respiratory Diseases)
10) çkeò hkuøk suÚke StËøkeLku òu¾{ (Any other Life threatening Diseases)

rðrþü LkkUÄ :
{khk yr¼«kÞ {wsçk íku{Lku MLkkLkkøkkh{kt Ëk¾÷ ÚkðkLke ÃkhðkLkøke ykÃke þfkÞ / þfkÞ Lkrn.

{urzf÷ ykuVeMkhLke Mkne íkÚkk rMk¬k

ÃkwY Lkk{ :
(Full Name)
MkhLkk{wt
(Address)
hS. Lkt.
(Reg. No.)
íkkhe¾ : / /20 rMk¬ku
(Stamp)
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