BARODA RAJASTHAN KSHETRIYA GRAMIN BANK (HEAD OFFICE : AJMER)

CHECK LIST FOR PERSONAL FILE

I (Name) _________________________________________ ROLL NO. : _____________________________ Email Id: _________________________________________ Personal Mobile No: ______________________ Caste/Category: ______________ (SC/ST/OBC/PC/EXS/Others) PWD ________________% OF DISABILITY__________________

Provisionally allotted for the post of Office Assistant (M)/ Officer Scale-I / Officer Scale- II (GBO / LAW / IT ) /Officer Scale­ III, reported at Baroda Rajasthan Kshetriya Gramin Bank, Head office, Ajmer for Pre-Joining

formalities and submitted following Forms/ Documents duly attested by me.

NAME OF CERTIFICATE/DOCUMENT MARK ( √ )

by

Candidate

MARK ( √ ) or Comments

of Verifying Officer

1 Date Of Birth Certificate

2 Educational Qualification Certificates

3 S.S.C.

4 H.S.C.

5 Graduation

Post-Graduation

Others

6 Hindi Language (As one of the subject in above

Educational Certificate)

7 Computer Literacy Certificates/ one of the subject

in above Educational Qualifications

8 Experience Certificate

9 Caste Certificate (For SC/ST/OBC Candidates)

10 OBC Creamy Layer Clause In Certificate

11 Medical Certificate From Medical Board (For PC

Candidates)

12 Satisfactory Report / Character Certificate

(From two Authority)

13 Discharge Certificate (For Ex-Servicemen)

14 ID Proof

15 CRP RRB – VII Score Card/ Combine Result with

Allotted Bank Name Issued by IBPS

16 Passport Size Photograph – Four

17 NOC/ Relieving Order issued by Present

Employer

18 IBPS Application Form

19 Copy of Pre Recruitment Formalities Call Letter

20 Police Verification Report

Form

No. Pre Recruitment Formalities Form MARK ( √ )

by

Candidate

MARK ( √ ) or Comments

of Verifying Officer

F-1 Service Entry Cum Bio-Data Form

F-2 Declaration By SC/ST/OBC Candidates

F-3 Declaration Of Marital Status (Schedule-I)

F-4 Declaration On Fidelity & Secrecy (Schedule-II)

F-5 Declaration Of Domicile (Schedule-III)

F-6 Undertaking (For Ex-Serviceman)

F-7 Letter Of Undertaking (At the time of Reporting)

F-8 Report Of Referees

Individually filled by two Referees(As name mentioned by you in Form F­8)

F- 8­1

Identity Form

F-9

Attestation Form

F-10

F-11

F-12

Place: Signature Of Candidate

Date : NAME _____________________

Signature Of Verifying Officer

NAME _____________________

Place: E.C. NO. _____________________

Date : DESIGNATION _____________________

BARODA RAJASTHAN KSHETRIYA GRAMIN BANK

(HEAD OFFICE : AJMER) F-1

lsok izfof’V ,oa ckW;ksMsVk QkWeZ

SERVICE ENTRY CUM BIO-DATA FORM

1. (a) iwjk uke ¼cM+s v{kjksa esa½

Full Name (IN BLOCK LETTERS) : ______________________________________

(b) firk dk uke

Father’s Name : ______________________________________

2. orZeku irk Present Address : ______________________________________

______________________________________

______________________________________

LFkk;h irk Permanent Address : ______________________________________

______________________________________

______________________________________

3. tUe rkjh[k Date of Birth : ______________________________________

4. oxZ lkekU; v-tk- vttk v-fi-o- fodykax HkwiwZolSfud

Category : (a) Gen SC ST OBC PC XSM

5. inuke Designation : ______________________________________

6. Js.kh@osrueku Grade / Scale : ______________________________________

7. ifjokj ds lnL;ksa dk C;kSjk %

Details of family members :

uke

Name

fj”rk

Relation

mez

Age

vkfJr

Whether dependent

(Y / N)

O;olk; dk

C;kSjk

Details of occupation

ekfld osru

Salary per month (Rs.)

8. igpku dk fpUg

Identification Mark : ______________________________________

9. D;k vki cSad ds fdlh funs”kd ;k deZpkjh

ds fj”rsnkj gS \ ;fn gks] d`i;k ,sls O;fDr

dk iwjk C;kSjk] cSad esa mldh gSfl;r rFkk

D;k fj”rk gS] ;g n”kkZ,a

Are you a relative of any Director : ______________________________________ or the employee of the Bank? If so, ______________________________________ please give the full name of such ______________________________________ person, his position in the Bank & ______________________________________ nature of relationship.

10. ewy fuokl dk LFkku Place of Domicile : ______________________________________

11. vius “kS{kf.kd dk;Zdky ds nkSjku ;fn

vkius dksbZ O;ogkfjd izf”k{k.k fy;k gks]

rks mldk C;kSjk nsaA

Give details of any practical training : ______________________________________ you had as a part of your academic ______________________________________ career / training ______________________________________

………..2

F-1

(2)

12. D;k vkidks fdlh izdk”ku dk Js; feyk gS\

¼isilZ] ys[k bR;kfn½ ;fn gks] d`i;k C;kSjk nsaA

Have you any publication to your : ______________________________________ credit (Papers, articles, etc.) ? If so, ______________________________________ please give details. ______________________________________

13. D;k vki vkxs fdlh ikB~;Øe gsrq v/;;u

dj jgs gSa\ ;fn gkWa] d`i;k C;kSjk nsaA

Are you studying for any further : ______________________________________ course ? If so, please give details. ______________________________________

14. D;k vki fdlh O;olkf;d@jktdh; fudk;@

fudk;ksa ds lnL; gS\ ;fn gkW] d`i;k C;kSjk nsaA

Are you, a member of any professional /: _____________________________________ political body / bodies ? If yes, please _____________________________________ give details. _____________________________________

15. D;k vkius fons”k ;k=k dh gS@;fn gks]]

d`i;k mldk m)s”;] vkids fons”k esa jgus

dh vof/k rFkk dksbZ vuqHko vftZr fd;k gks]

rks mldk C;kSjk nsaA

Have you traveled abroad ? If so, : ______________________________________ please give details about the purpose, ______________________________________ duration of your stay abroad, any ______________________________________ experience gained etc. ______________________________________

16. D;k vki dHkh fxj¶rkj gq, gSa vFok vfHkj{kk

esa j[ks x, gSa vFkok fdlh U;k;ky; }kjk

vkc) fd;s x, gSA vki ij tqekZuk yxk;k

x;k gS ;k fdlh ijh{kk esa cSBus ij jksd

yxk;h x;h gSA vki v;ksX; ?kksf’kr fd;s x,

gS vFkok fdlh izkf/kdkjh@laLFkku }kjk dksbZ

izfrca/k yxk;k x;k gS\ ;fn gkWa] rks iw.kZ nsaA

Have you ever been arrested or kept : ______________________________________ under detention or bound/fined/ ______________________________________ convicted by court of law or debarred/ ______________________________________ disqualified from any examination or ______________________________________ restricted by any authority / Institution? ______________________________________ If yes, give full details.

17. vU; dksbZ lwpuk tks vki nsuk pkgsaA

Any other information you would like : ______________________________________ to give. ______________________________________

18. eSa fdlh Hkh LFkku ij tgkWa cSad dh “kk[kk ;k

dk;kZy; gS ;k vc ds ckn [kksyh tk,] esa cSad

dh lsok djus gsrq bPNqd gwa vkSj eSa cSad

}kjk le;≤ ij r; dh tkrh lsok “krksZa

ls vkc) jgus gsrq lger gwaA eSa uksV djrk gWaw]

fd ifjoh{kk dh vof/k ds nkSjku esjh lsok,a cSad }kjk

fcuk fdlh dkj.k n'kkZ, lekIr dh tk ldsxhA

I am willing to serve the Bank anywhere the Bank ..............................................has or might hereafter open office or branches and agree to be bound by the terms and conditions of services laid down by the Bank from time to time.I note that during the period

of probation, my services are liable to be terminated by the Bank without assigning any reason whatsoever for such termination.

………..3

F-1

(3)

eSa ,rn~}kjk lger gksrk gwa] fd eq>s vkids }kjk lsok esa fy;s tkus ij] cSad ;k mlds xzkgdksa ds ekeyksa ls

lacaf/kr dksbZ Hkh tkudkjh esjs ikl gksxh] mls eSa vR;Ur xksiuh; j[kwaxk vkSj fdlh Hkh le; fdlh ds le{k

mls izdV ugha d:axkA

I hereby agree that in the event of my being taken up in your services, any information concerning the affairs of the Bank or its clients of which I may become possessed, shall be held by me in strict confidence and shall not be divulged to anyone at any time.

eSaus mDr QkWeZ rFkk ckW;ksMsVk QkWeZ Hkjk gS vkSj eSaus ml ij lko/kkuh ls fopkj djrs gq, vkSj le> dj

opu fn;k gS rFkk ,rn~}kjk Hkh eSa ?kksf’kr djrk gwWa] fd esjs mDr nksuksa izksQkWekZ esa nh tkudkjh lR; gS rFkk

esjh tkudkjh ,oe~ fo”okl ls lgh gSA

I have filled in the above form and have given the undertaking after carefully considering and understanding it and I hereby declare that the information given by me in both these forms is true and correct to the best of my knowledge and belief.

eSa vkxs bl ckr ds fy, Hkh lger gwWa] fd esjs }kjk mDr QkWeZ rFkk ckW;ksMsVk QkWeZ esa nh xbZ] ftl

tkudkjh ds vk/kkj ij cSad }kjk esjh fu;qfDr dh xbZ gS] og xyr ik;h tkrh gS] rks mls ,d xaHkhj

dnkpkj ekuk tk,xk vkSj blls cSad esa esjh lsok,a] rRdky c[kkZLr dh tk ldsxhA

I further agree that in the event of any information given by me in the above form and bio-data form, on the basis of which my appointment is considered by the Bank, is found to be false, it will constitute serious misconduct which will render me liable to immediate dismissal from the Bank’s service.

LFkku %

Place : ________________________

fnukad %

Date :_________________________

gLrk{kj @ Signature

iwjk uke %

Full Name :_________________________

eksckbZy ua-:_________________________

bZ&esy irk:_________________________

F-2(SC/ST)

DECLARATION TO BE SIGNED BY SC/ST CANDIDATES ONLY

I__________________________________son/daughter/wife of _________________

_______________resident of village/town/city________________________

district______________________state___________________ hereby declares that

I belong to the________________________ community which recognized as

Scheduled caste / Scheduled Tribe by the Government of India for the purpose of

reservation in Central Government Services under various constitutional orders.

It is also declared that the caste certificate submitted by me shall be deemed to be

material for the purpose of this appointment. If the any information contained in

the Caste Certificate is found false or incomplete my services are liable to be

terminated at any point of time as appointment having been secured on

misrepresentation/ supersession.

Signature of the Candidate (Name _________________________)

Mobile No.______________________

Place: ____________

Date : ____________

F-2(OBC)

DECLARATION TO BE SIGNED BY OBC CANDIDATES ONLY

I__________________________________son/daughter/wife of shri______________

_____________________resident of village/town/city________________________

district______________________state___________________ hereby declares that

I belong to the________________________ community which recognized as a

backward class by the Government of India for the purpose of reservation in

Services as per orders contained in Deptt. of Personnel and Training Office

Memorandum No. 36102/22/93-Estt. (SCT) dated 08.09.1993. It is also declared that

I do not belong to the persons/sections (creamy layer) mentioned in Column 3 of

the schedule to the OM No-36102/22/93-Estt (SCT) dated 08.09.1993 and modified

vide Govt. of India Deptt. Of Personnel and Training OM No. 36033/3/2004-Estt

(Res) dated 09.03.2004.

It is also declared that the caste certificate submitted by me shall be deemed to be

material for the purpose of this appointment. If the any information contained in

the Caste Certificate is found false or incomplete my services are liable to be

terminated at any point of time as appointment having been secured on

misrepresentation/ supersession.

Signature of the Candidate (Name _________________________)

Mobile No.______________________

Place: ____________

Date : ____________

F-3

SCHEDULE – I

[See regulation 5(4)(ii)]

DECLARATION OF MARITAL STATUS

I, Shri/Smt/Kum ________________________________________ s/o w/o

d/o ______________________________________ declare as under:

(i) That I am unmarried/a widower/widow.

(ii) That I am married and have only one spouse living.

(iii) That I have entered into or contracted a marriage with a person

having a spouse living. I may be granted exemption on the basis of

ground given below. Application for grant of exemption is enclosed.

Ground:

2. I solemnly affirm that the above declaration is true and I understand that

in the event of the declaration being found to be incorrect after my

appointment, I shall be liable to be dismissed from service.

Date: Signature of Candidate

Place :

SCHEDULE - II F-4

(See regulation 19)

DECLARATION OF FIDELITY AND SECRECY

I, _____________________________, do hereby declare that I will faithfully,

truly and to the best of my skill and ability execute and perform the duties

required of me as officer or employee of the

Baroda Rajasthan Kshetriya Gramin Bank and which properly relate the office or

position held by me in the said Bank.

I further declare that I will not divulge or allow to be divulged to any person not

legally entitled thereto any information relating to the affairs of the said Bank or

to the affairs of any person having any dealing with the said Bank and nor will I

allow any such person to inspect or have access to any books or documents or

electronic records belonging to or in possession of the said Bank and relating to

the business of the said Bank or the business of any person having any dealing

with the said Bank.

Signature:

Place : Name in full:

Date : Designation:

Signed before Verifying Officer

Signature:

Name in full:

Designation:

E.C.No. :

F-5

SCHEDULE – III

(See regulation 73)

DECLARATION OF DOMICILE

I, the undersigned having been appointed in the service of

the.....................Bank hereby declare.....................(Place)

in.......................(District) as my place of domicile.

1. * The above is my place of birth.

or

* The above is not my place of birth. my place of birth is..........(Place)

in...............(District) but ................(Place) has been declared as my place of

domicile for the reasons given below.

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

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

Date : Signature :

Place : Name :

Designation :

* Strike out whichever is not applicable.

F-6

UNDERTAKING

(FOR EX-SERVICEMAN)

I confirm that I am entitled to the benefits admissible to ex-servicemen in terms of

the Ex-Servicemen (Re-employment in Central Civil Services and Posts) Rules,

1979, as amended from time to time and I have been duly

released/retired/discharged from the Armed Forces on ___________ (copy of discharge

book enclosed).

2. I confirm that I have not at any time prior to this appointment, secured any

employment on the civil side (including Public Sector Undertakings, Autonomous

Bodies/Statutory Bodies, Nationalized Banks, etc.), by availing of the concession

of reservation of vacancies admissible to Ex-servicemen.

3. I understand that if my above claim is false my services will be terminated

forthwith without assigning any further reasons and without prejudice to such

further action as may be taken under the provisions of Indian Penal Code (IPC) for

submitting false undertaking.

Place :

Date : Signature of candidate

Name : __________________________

Address : ________________________

_________________________________

_________________________________

F-7

Letter of Undertaking

I, ______________________________________________________________________

S/o.______________________________R/o.(Res.Add)_________________________

refer to your letter No. HO/2019-20/HRM/_________ dated __________advising me about

my appointment as Office Assistant (Multipurpose)/ Officer Scale I/ Officer Scale II(GBO/LAW/IT) / Officer Scale III. I understand that the offer made to me is provisional & subject to

1. Fulfilling all the prescribed eligibility criteria. 2. My being found medically fit and 3. Submission of various documents / certificates and mentioned in the offer letter.

The said documents submitted by me shall be deemed to be material for the purpose of this appointment. I hereby state that I fulfill the prescribed eligibility criteria and all the copies of documents / certificates submitted by me are correct and in order and shall be deemed to be material for the purpose of selection. I undertake that the documents, information, statements and claims are true to best of my knowledge. In case, any thing is found to be false and/or incomplete resulting in non-fulfillment of eligibility criteria as prescribed, my candidature / appointment would be treated as void ab-initio and the services are liable to be terminated, as having been secured on mis-representation, false representations and / or suppression of facts with a motive to gain employment.

Signature of the Candidate (Name _________________________) Place: ____________

Date : ____________

F-8

BARODA RAJASTHAN KSHETRIYA GRAMIN BANK HEAD OFFICE: AJMER

Report of Referees

Name of Post: ____________________________ Name of the Candidate: _____________________ Father’s Name: ____________________________ Please furnish Name and Address of two respectable persons, preferably known to the Bank and not related to you for reference :- Referee(1) _____________________________

___________________________________

___________________________________

___________________________________

Mobile No.___________________________

Referee(2) ____________________________

___________________________________

___________________________________

___________________________________

Mobile No.___________________________

Place :

Date : Signature of candidate

Name : __________________________

Address : ________________________

_________________________________

_________________________________

izek.k i= (jsQjh dh fji¨VZ)

izekf.kr fd;k tkrk gS fd Jh@Jherh@dq------------------------------------------------------------------------------------------------

iq=@iRuh@iq=h--------------------------------------------------------------fuoklh-------------------------------------------------------------------------

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

d¨ eSa fiNys ---------------------o“k¨± ls Hkyh HkkfUr tkurk o igpkuRkk gw¡ o budh igpku dh iqf“V

djrk gw¡ I budk pfj= mRre gS I

_________________ izekf.krdrkZ d¢ gLrk{kj

*uke&

*O;olk; &

*lEiw.kZ irk &

*e¨ckby la0&

*;g vfuok;Z lwpuk,a gSa ftudk Hkjk tkuk vko‘;d gS rFkk izekf.krdrkZ O;fDr ¼jsQjh½ ds igpku o irk

lEcU/kh izek.k tSls& vk/kkj dkMZ] ikli¨VZ] Mªkbfoax ykblsUl ;k Q¨V¨ yxh cSad ikl cqd dh Loizekf.kr dkih layXu

g¨uk vko‘;d gS

F8­1Referee 1

izek.k i= (jsQjh dh fji¨VZ)

izekf.kr fd;k tkrk gS fd Jh@Jherh@dq------------------------------------------------------------------------------------------------

iq=@iRuh@iq=h--------------------------------------------------------------fuoklh-------------------------------------------------------------------------

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

d¨ eSa fiNys ---------------------o“k¨± ls Hkyh HkkfUr tkurk o igpkuRkk gw¡ o budh igpku dh iqf“V

djrk gw¡ I budk pfj= mRre gS I

_________________ izekf.krdrkZ d¢ gLrk{kj

*uke&

*O;olk; &

*lEiw.kZ irk &

*e¨ckby la0&

*;g vfuok;Z lwpuk,a gSa ftudk Hkjk tkuk vko‘;d gS rFkk izekf.krdrkZ O;fDr ¼jsQjh½ ds igpku o irk

lEcU/kh izek.k tSls& vk/kkj dkMZ] ikli¨VZ] Mªkbfoax ykblsUl ;k Q¨V¨ yxh cSad ikl cqd dh Loizekf.kr dkih layXu

g¨uk vko‘;d gS

F8­1Referee 2

F-9

BARODA RAJASTHAN KSHETRIYA GRAMIN BANK

HEAD OFFICE: AJMER

IDENTITY FORM

1. Full Name:

2. Designation:

3. Qualification:

4. Father’s Name and Occupation:

5. Caste:

6. Complete Home Address:

7. Present Address:

8. Mobile No. :

9. E-Mail Address :

10. Date of Birth :

11. Height :

12. Mark of Identification:

13. Relationship with any employee or Director of the Bank (give names and relationship in

vernacular)

14. Left hand thumb impression:

15. Signature of employee:

16. Initial of the employee:

Place:

Date: Signature and Designation of the Verifying Officer

Affix passport size photograph

duly attested

:

F-10 BARODA RAJASTHAN KSHETRIYA GRAMIN BANK

(HEAD OFFICE : AJMER)

lR;kiu QkWeZ

ATTESTATION FORM

d-dw-la- EC No.: ___________

lR;kiu QkeZ esa xyr lwpuk nsuk ;k rF;kRed lwpuk dks nckdj j[kuk mEehnokj

dks v;ksX; ?kksf’kr dj ldrk gS vkSj ,slk gksus ij mEehnokj dks cSad esa fu;qfDr ds

fy, v;ksX; Bgjk;k tk ldrk gSA ;fn lR;kiu QkWeZ esa xyr lwpuk nh xbZ gS ;k

rF;kRed lwpuk dks nckdj j[kk x;k gS vkSj ;g rF; fdlh O;fDr ds lsok ds

le; /;ku esa vkrk gS] rks mldh lsok lekIr dh tk ldrh gSAThe furnishing of

false information or suppression of any factual information in the attestation form would be disqualification and is likely to render the candidate unfit for appointment in the Bank. If the fact that false information has been furnished or there has been suppression of any factual information in the attestation form comes to notice any time during the service of a person, his/her service would be liable to be terminated.

1 iwjk uke ¼cM+s v{kjksa esa½ miuke ds lkFk fy[ksa]

;fn dksbZ gS ¼;fn vkius fdlh Hkh Lrj ij dksbZ

uke ;k miuke tksM+k gS ;k NksM+k gS] rks d`I;k

mYys[k djsa½

Name in full (in Block Capital) with aliases, if any (Please indicate if you have added or dropped at any stage any part of any name or surname)

SURNAME NAME

2 iwjk orZeku irk ¼vFkkZr xkao] Fkkuk vkSj

ftyk ;k edku la- ykbu@LVªhV @jksM vkSj

“kgj½ Present address in full (i.e. Village,

Thane and District or House No. Lane/ Street/Road and Town)

3. ¼d½ iwjk LFkk;h irk ¼vFkkZr xkao Fkkuk vkSj

ftyk ;k edku la- ykbu@LVªhV@jksM “kgj

vkSj ftys dk eq[;ky; dk uke½

(a) Permanent Address in full (i.e. Village, Thane and District or House No. Lane/ Street/Road,Town and name of the Distt. H.Q.

¼[k½ vxj ewy :i ls Hkkjr ds vykok fdlh

vU; ns”k ds fuoklh gSa] rks ml ns”k dk irk

vkSj Hkkjrh; la?k esa LFkkukUrj.k dh rkjh[k

(b) If originally a resident of country other than India, the address in that country and the date of migration to Indian Union.

4. mu LFkkuksa ds fooj.k ¼fuokl dh vof/k lfgr½ tgka vki fiNys ikap o’kksZa ds nkSjku ,d ls vf/kd

o’kksZa rd jgs gSaA

Particulars of places (with period residence) where you have resided for more than one year at a time during the preceding five years.

ls

From

rd

To

iwjk fuokl dk irk ¼vFkkZr xkao]

Fkkuk vkSj ftyk edku la[;k ds fy,

ykbu@LVªhV@jksM+ vkSj “kgj½

Residential Address in full (i.e. Village, Thane & Dist. for House No. Lane/Street/Road and Town)

iwoZorhZ dkWye esa mfYyf[kr

LFkku ds ftyk eq[;ky; dk

uke Name of the Distt.

Headquarters of the place mentioned in the preceding column

……….. 2

Affix passport size photograph

F-10 (2)

5.1 ¼d½ firk dk iwjk uke miuke ds lkFk] ;fn dksbZ gks rks

(a) Father’s Name in full with alias, if any : _________________________________

¼[k½ orZeku Mkd irk

¼vxj e`R;q gks xbZ rks vafre irk½ : _________________________________

(b) Present Postal Address __________________________________ (If dead, give last address) __________________________________ _________________________________

¼x½ LFkk;h irk (c) Permanent Address : _________________________________

_________________________________ _________________________________ _________________________________

¼?k½ is”kk (d) Profession : _________________________________

¼M-½ vxj lsok esa gS] rks inuke vkSj dk;kZy; irk : _________________________________

(e) If in service, give designation and _________________________________ official address _________________________________

5.2 ¼d½ ifr@ifRu dk iwjk uke

(a) Spouse’s name in full : _________________________________

¼[k½ is”kk

(b) Profession : _________________________________

¼x½ inuke vkSj dk;kZy; irk

(c) Designation and Office Address : _________________________________ _________________________________ _________________________________

6. ukxfjdrk @ Nationality of

¼d½ firk @(a) Father : _________________________________

¼[k½ ekWa @ (b) Mother : _________________________________

¼x½ ifr@ifRu (c) Spouse : _________________________________

7. ;FkkZr tUe frfFk Exact date of Birth : _________________________________

orZeku vk;q @ Present Age : _________________________________

eSVªhd ds le; vk;q Age at Matriculation : _________________________________

8. ¼d½ tUe LFkku (a) Place of Birth : _________________________________

¼ftyk vkSj jkT; tgak fLFkr gS½

(Distt. & State in which situated) _________________________________

¼[k½ ftyk vkSj jkT; tgak ds jgus okys gks

(b) Distt. & State to which you belong : _________________________________

9. ¼d½ vkidk /keZ (a) Your Religion : _________________________________

¼[k½ D;k vki vuq-tkfr@vuq-tutkfr ds lnL;

gS\ vxj mRrj gkWa gS] rks bldk uke crk,a

(b) Are you a member of a Scheduled Caste /: _________________________________ Scheduled Tribe ? If the answer is yes, _________________________________ state the name thereof.

10. “kS{kf.kd ;ksX;rk,a] ftlesa 15 lky dh vk;q ls ysdj f”k{kk dk LFkku o o’kksZa ds lkFk Ldwy vkSj dkWyst

dk LFkku n”kkZ;k x;k gksA

Educational qualifications showing place of education with years in Schools and Colleges since 15th year of age.

¼iwjs irs ds lkFk½

Ldwy@dkWyst Name of

School/College with full address

izos”k djus dh

rkjh[k

Date of entering

NksM+us dh rkjh[k

Date of leaving

mRrh.kZ djus dk o’kZ

Year of Passing

…….. 3

F-10

(3)

11. ;fn vki fdlh Hkh le; lsok esa jgs gSa] rks mldk fooj.k nsaA

If you have, at any time, been employed, give details.

/kkfjr in dk uke]

fu’ikfnr dk;Z

Designation of post held of

description of work

vof/k Period dk;kZy;] O;olk;

izfr’Bku ;k laLFkku

dk iwjk irk

Full address of the Office, Firm or

Institution

lsok dks NksM+dj

tkus dh otg

Reasons for leaving the job

ls @ From rd @To

12. D;k vkidks dHkh fxj¶rkj fd;k x;k gS] utjcanh fd;k x;k gS ;k fdlh vijk/k ds fy, vkidks fdlh

U;k;ky; }kjk izfrcaf/kr fd;k x;k gS@tqekZuk yxk;k x;k gS@ltk nh xbZ gS vFkok la?k yksd lsok

vk;ksx }kjk ijh{kk esa Hkkx ysus ij jksd yxkbZ gS\ ;k vkidks fo”ofo|ky;@ izkf/kdj.k@laLFkk ls

izfrcaf/kr@fdlh Hkh ijh{kk esa cSBus ls oftZr@fu"dkflr fd;k x;k gks\

vxj mRrj ^gkWa* gS] rks dsl dk iwjk C;kSjk] tqekZuk] nks’k flf)] n.Mkns”k vkfn dk mYys[k djsaA

Have you ever been arrested or kept under detention or bound down / fined / convicted by a Court of Law for any offence or debarred / disqualified/restricted by the Public Service Commission from appearing at its examination selections or debarred from taking any examination or restricted by University/authority / institution?

If answer is “YES” full particulars of the case detention, fine, conviction, sentence etc., should be given. ______________________________________________________

____________________________________________________________________________

13- D;k bl vuqizek.ku QkeZ dks Hkjrs le; fdlh Hkh U;k;ky; fo'ofo|ky; ;k fdlh Hkh 'kS{kf.kd

izkf/kdj.k@laLFkk esa vkids fo:) dksbZ ekeyk yfEcr gS ;fn ¼d½ vFkok ¼[k½ esa iwNs x;s iz'uksa ds

laca/k esa vkids mÙkj gk¡ esa gks rks vkidks bl vuqizek.ku QkeZ Hkjrs le; ekeys] fxj¶rkjh] fujks/k

tqekZus] nks"kfl) rFkk n.Mkns'k vkfn ds iwjs C;kSjs izLrqr djus pkfg,A rkfd bl QkeZ dks Hkjrs le;

U;k;ky;@fo'ofo|ky;@'kS{kf.kd izkf/kdj.k vkfn ds le{k tks ekeyk yfEcr gks mldk Lo:i

crykuk pkfg, bl tkudkjh ds vfrfjDr tgka ykxw gks ogka fuEufyf[kr C;kSjs Hkh fn;s tk;sxsa%&

Øekad en gk¡@ykxw ugha ¼;fn gk¡] rks fooj.k

Hkh nsa½

1 vijk/k@vkjksi

2 iqfyl Fkkus esa iathc)

3 ;fn U;k;ky; esa pkyku izLrqr fd;k x;k gks rks U;k;ky; dk

uke

4 ekeys dk Ø-@U;k;k- }kjk mldk fuiVkjk fdl frfFk dks

fd;k x;k

5 fn;k x;k n.M

6 D;k nks"keqDr dj fn;k x;k\

…….. 4

__

____________________________________________________________________________

F-10 (4)

7 nks"keqfDr lansg ds ykHk ij vk/kkfjr Fkh ;k ekeyk okil ys

fy;k x;k Fkk\

8 D;k fdlh ,sls laxze ;k laxBu tks ljdkj }kjk fof/k fo:)

?kksf"kr fd;k x;k Fkk vFkok fd;k x;k gS] ds lnL; gS ;k

mlds lg;ksxh jgs gSa\ ;fn ,slk gks rks iw.kZ fof'kf"V;ka nsa]

tSls laxze@laxBu dk uke lnL;rk vFkok lEc)rk dh

dk;Zokgh vof/k bR;kfnA

;fn bl QkeZ dks Hkjus vkSj Hkstus ds ckn mEehnokj dks utjcan ;k fxj¶rkj fd;k tkrk gS vFkok ml ij

eqdnek pyk;k tkrk gS ;k mls canh cuk;k tkrk gS rks vFkok ml ij tqekZuk fd;k tkuk ;k mls nks"k

fla) ik;k tkrk vFkok mls fooftZr fd;k tkrk gS ;k nks"keqDr fd;k tkrk gS rks C;kSjs ;FkkfLFkfr] jkT;

yksd lsok vk;ksx ;k ml izkf/kdkjh dks ftls vuqizek.ku QkeZ igys Hkstk x;k gks] rRdky lwfpr fd;s tkus

pkfg;s vFkok ;g ekuk tk,xk fd rF;kRed tkudkjh fNikbZ xbZ gS] vr% ;g Lo;a mEehnokj ds fgr esa

gksxk fd og mu ekeyksa ds iwjs C;kSjs izLrqr djsa] ftuesa mls fxj¶rkj fd;k x;k Fkk] ml ij vfHk;kstu

pyk;k x;k Fkk] vkfn Hkys gh ekeys esa vfUre :i ls izfrosfnr dj fn, gks ¼[kkRek½ okil ys fy, gks ;k

muesa vUrr% nks"keqfDr gks xbZ ;k le>kSrk dj fy;k x;k gksA

;fn rF; fd vuqizek.ku QkeZ esa vlR; tkudkjh nh xbZ gS ;k ;g fd dksbZ rF;kRed tkudkjh fNikbZ xbZ

gS] fdlh O;fDr dh lsok ds nkSjku fdlh Hkh le; /;ku esa vk, rks] mldh lsok,a lekIr dh tk ldsaxhA

DECLARATION

eSa] izekf.kr djrk@djrh gwWa] fd iwoksZDr lwpuk esjh loksZre tkudkjh vkSj fo”okl ds vuqlkj lgh vkSj iw.kZ

gSA eSa ,slh fdlh ifjfLFkfr ls ifjfpr ugha gwa] tks eq>s cSad esa jkstxkj gsrq esjh ;ksX;rk dks {kfr igqapk

ldrh gSA esjs vkosnu i= esa esjs }kjk fn;s x, dFku ds laca/k esa iqfyl tkap iM+rky lfgr cSad }kjk dksbZ

Hkh tkap dHkh Hkh fdlh Hkh le; ¼rqjar@fudV Hkfo’; esa½ ij djus esa eq>s Hkh vkifRr ugha gSA

I certify that the foregoing information is correct and complete to the best of my knowledge and belief. I am not aware of any circumstance which might impair my fitness for employment in the Bank. I have / will have no objection to the Bank making enquiries at any time (immediately / in the near future) regarding the statement made by me in the application. In any manner they decide to do so inclusive of police enquire into my antecedents.

fnukad @ Date : mEehnokj ds gLrk{kj

LFkku @Place : Signature of Candidate

EXPERIENCE CERTIFICATE

(To be issued on letter head)

This is certify that Mr/Mrs/Miss....................................S/D/W/O....................................

is/was employee of Our Bank/Organization. He/ She was appointed in Officer

Cadre/…………………….. and working/worked as.....................................

(Designation) in our Bank/ Organization since.................... to ......................../till date.

Adverse report/ D.E. pending or contemplated (If any) belongs to Mr./Mrs./

Miss......................are as under : –

…………………………………………………………………………………………………..

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

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

Seal and Signature of Appointing Authority

Full Name:

Designation:

Name of Bank/Organization:

E-mail ID:

Tel. No. :

Place:

Date:

CHARACTER AND ANTECEDENTS VERIFICATION REPORT (APPLICATION FORM)

To The Superintendent of Police, District Police Office,__________

Subject : Application for Employee Verification

Sir,

It is requested that I have been selected as............................................in Baroda Rajasthan Kshetriya Gramin Bank, a Bank constituted under the RRB Act, 1976 and having its Head Office at Plot No. 2343, IInd Floor, Vaishali Nagar, Ajmer-305 004. The Bank requires that my character and antecedents may be verified and a Police Verification Report may be issued to me. My personal particulars are as follow:-

1. Full Name (Expanded Initials) : ......................................................... Alias (if any) : .........................................................

2. Father (Full Name) : ......................................................... 3. Spouse (Full Name), if married : ......................................................... 4. Occupation: ......................................................... 5. Nationality : ........................Age..............Sex..............Caste.............. 6. Mobile No............................ 7. Permanent Address:-

H.No. ............................Sector/Village/Locality............................ Police Station............................District........................................ State..........................................Pincode......................................

8. Proof of Identity (Voter Card/Driving Licence/Ration Card etc.) 9. Local (Current Address) : .........................................................

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

Residing at current address since : .......................................... 10. Particulars of Previous Employment, If any

Nature of Employment ......................................................... Address : .............................................................................

.............................................................................. .............................................................................. Particulars of Previous Employer..........................................

11. Particulars of relatives residing locally (Current) Local Address S.No. Name Father's Name Occupation Local Address (1) ....................... .......................... ........................ ....................... (2) ....................... .......................... ........................ ....................... (3) ....................... .......................... ........................ .......................

(Signature of Applicant)

(For use of S.P. Office) Name of the Applicant : ........................................................ Father/Husband's Name : .....................................................

Address : .............................................................................. .............................................................................

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

Report : ................................................................................................................................. ............................................................................................................................................... ............................................................................................................................................... ...............................................................................................................................................

(Signature of the issuing Authority)

Official Seal

Photo

(Self signed)

Photo

(Attested by issuing

Authority)