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 FI - Annexure-VII (I)
CHANKYA E-SERVICES PVT.LTD
Corporate Office-
Office Plot No.23 Sector-F Shrinagar Colony,N-5 Cidco
CHANKYA E-SERVICES PVT. LTD. Corporate Office, STPI, PLOT NO. T-25, BLOCK -D, CHIKALTHANA
Au
Aurangabad
MIDC, Chh. Sambhajinagar (AURANGABAD)431001 Mob-7756837111
- 431 007, Maharashtra, INDIA
Mob - [email protected]
Email-support.bc@cEmail - [email protected] website www.cesindia.org
website www.chankyaeservices.in

CSP APPLICATION FORM

Bank Of India Application Form BCA

01. Location (Village / Town)

Link Branch Name

Link Branch IFSC Code

Village Panchayat

Block District

State Pin

02. Full Name (IN BLOCK LETTERS)

03. Father’s/Husband’s Name (IN BLOCK LETTERS)

04. Date of Birth 05. Gender (Please Tick) 06. Marital

rital Status (Please Tick)
D D M M Y Y Y Y Male Female Marrie
arried Unmarried

07. Telephone No. (With STD Code)

Residence Office Mobile

08. Email (if any)

09. Education (Please Tick)

Class X Class XII Graduate Post Graduate and above

a

10. Permanent Address

Village Panchayat

Block District

State Pin

11. Communication / Office Address

Village Panchayat

Block District

State Pin

12. Currently Banking With (Bank Name) 13. Bank Account Number, if any

14. Aadhar Number 15. PAN Number

 FI - Annexure-VII (I)
16. Cheque Book Facility (Please Tick)

Available Not Available

17. *Proof of Name (Please Tick)

Driving License PAN Card Voter ID Card Passport Aadhar Card

18. *Proof of Address (Please Tick)

Electricity Bill NSC Copy Telephone Bill LIC Copy Landlord Letter Gas Recipt

19. Present Business / Occupation, if any 20. Computer Literacy Yes No

21. Revenue / Income per month including pension 22. Any experience in selling financial products?
Rs.

23. Languages Known English Hindi Marathi Any other (Specify)

(Please Tick)

24. No. of years of stay in the Town / Village In Town Years I In Village Years

25. Do you have any Police Records? Yes No

26. Name, Address and occupation of two people to whom reference can be made.
st
1 Reference Name

Village Panchayat

Block District

State Pin

Occupation Contact No.

nd
2 Reference Name

Village Panchayat

Block District

State Pin

Occupation Contact No.

I hereby Undertake / Declare that :

i) Aforesaid information furnished by me is correct and true to the best of my knowledge and belief and in case found at any stage that the information
given by me/us is wrong, my/our engagement as Business Correspondent will be cancelled
ii) I/we have read the details of the scheme for engagement as Business Correspondent / Business facilitator in the Bank of India, eligibility criteria,
terms & conditions, scope of the activity and payment of service charges, etc.
iii) In case my/our name(s) is/are considered for appointment as Business Correspondent. I/we will/shall sign the Agreement-cum-indemnity with
Bank of India as per the draft shown to me/us and abide by the terms of Agreement-cum-indemnity, rules/norms of the scheme.
iv) I/we fully agree that submission of this application/Bio-data to the Bank shall not be construed as a right for selection and Bank reserves its right to
select/reject the case on merit.

Date: / / (Signature of the applicant)

Place:................................ Full Name..........................................................................

Note: Please obtain the signature of the candidate on all the pages of application. Recommending Branch Official should verify the application &
documents. Please put the Branch seal & initial on the photo as well as application & documents.

2 | Page
 Financial Inclusion
Bio-Dat
Data of Business Correspondents Bank
Detail
etails of BC appointed by Corporate BC
Date -
Link Branch Name -
Branch Code -
IFSC Code –
District –
Distance From Branch -
Name of The Corporate BC Chankya E-Services Pvt. Ltd.

Name Of the Business Correspon

spondent

Father's/ Husband's Name

Pe
Permanent Address as per Aadhaar

Village / Town SSA / Ward

Block / Taluka District

State Pin

Aadhaar Card No. PAN No.

Mobile Number Email ID

Date Of Birth Gender

Education Marital Status

Communication / Office Address

Village / Town SSA / Ward / Landmark

Block / Taluka District

State Pin

I hereby undertake/decla
eclare that:
Aforesaid informationn fur
furnished by me is correct and true to the best
est of my knowledge
and belief and in case found at aany stage that the information given by me/u
e/us is wrong, my/our
respondent Agent will be cancelled. Also, I am not
engagement as Business Corresp n engaged as BC
of any other Bank/FI.

(Signature of the
he B
BC) (Authorized Signatoryy of the Corporate BC)

CHANKYA E-SERVICES PVT.LTD

Corporate Office- Plot No.2
o.23 Sector-F Shrinagar Colony,N-5 Cidco Aurangabad 431001 Mob-7756837111 Mo
CHANKYA E-SERVICES PVT. LTD. Corporate Office, STPI, PLOT NO. T-25, BLOCK -D, CHIKALTHANA
Email-suppo
[email protected]
MIDC, Chh. Sambhajinagar (AURANGABAD) - 431website www.chankyaeservices.in
007, Maharashtra, INDIA s.in
Mob - 9403181279 Email - [email protected] website www.cesindia.org
 SELF DECLARATION
To,
Branch Manager,
Bank of India,
Branch ……………...
IFSC Code ………………..
Pin ……………

I …………………………………………………………………… Residence at
…………………………………………………………………………………. having office at
…………………………………………………………………… declare that I will be an
applicant and I am required to submit the certificate after completing the IIBF examination
required to run the Customer Service Center within six months of receiving the Bank of
India Customer Service Center. Otherwise, I am fully aware that the decision taken by
the managers of Chankya E-Services Private Limited and Bank of India will remain with
either of them or the right to close my customer service center.

(Signature)
Name of the Applicant
Mob No:
Date:
Place: