BARODA RAJASTHAN KSHETRIYA GRAMIN BANK

(HEAD OFFICE : AJMER)

CHECK LIST FOR PERSONAL FILE

I (Name) _________________________________________ ROLL NO. : _____________________

Provisionally allotted for the post of Office Assistant (M)/ Officer Scale-I / Officer Scale- II reported
at Baroda Rajasthan Kshetriya Gramin Bank, Head office, Ajmer for Pre-Joining formalities and
submitted following Forms/ Documents duly attested by me.
Email Id: _________________________________________
Personal Mobile No: _______________________________

Caste/Category: ______________ (SC/ST/OBC/PC/EXS/Others)

PWD ______% OF DISABILITY_______

NAME OF CERTIFICATE/DOCUMENT MARK ( √ ) MARK ( √ ) or Comments

by of Verifying Officer
Candidate
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 CWE RRB – V 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
 Form Pre Recruitment Formalities Form MARK ( √ ) MARK ( √ ) or Comments
No. by of Verifying Officer
Candidate
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

F- 8­1 Individually filled by two Referees

F -9 Identity Form

F-10 Attestation Form

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 fj”rk mez vkfJr O;olk; dk ekfld osru
Name Relation Age Whether C;kSjk Salary per
dependent Details of month
(Y / N) occupation (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 gW]aw
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 gw]a 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[kwx
a k 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/2017-18/HRM/_________ dated __________advising me about

my appointment as Office Assistant (Multipurpose)/ Officer Scale I/ Officer Scale II.

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 :-

(1) ___________________________________
___________________________________
___________________________________
___________________________________
Mobile No.___________________________

(2) ___________________________________
___________________________________
___________________________________
___________________________________
Mobile No.___________________________

Place :
Date : Signature of candidate
Name : __________________________
Address : ________________________
_________________________________
_________________________________
 F8­1

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
 F-9
BARODA RAJASTHAN KSHETRIYA GRAMIN BANK
HEAD OFFICE: AJMER

IDENTITY FORM
Affix passport
size photograph
1. Full Name: duly attested
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
 F-10
BARODA RAJASTHAN KSHETRIYA GRAMIN BANK
(HEAD OFFICE : AJMER)
lR;kiu QkWeZ
ATTESTATION FORM

d-dw-la- EC No.: ___________

Affix passport
lR;kiu QkeZ esa xyr lwpuk nsuk ;k rF;kRed lwpuk dks nckdj j[kuk mEehnokj
size photograph
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 es½a miuke ds lkFk fy[ksa] SURNAME NAME
;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 djs½a
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)
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 rd iwjk fuokl dk irk ¼vFkkZr xkao] iwoZorhZ dkWye esa mfYyf[kr
From To Fkkuk vkSj ftyk edku la[;k ds fy, LFkku ds ftyk eq[;ky; dk
ykbu@LVªhV@jksM+ vkSj “kgj½ uke Name of the Distt.
Headquarters of the place
Residential Address in full (i.e.
mentioned in the
Village, Thane & Dist. for House No.
preceding column
Lane/Street/Road and Town)

……….. 2
 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 izos”k djus dh NksM+us dh rkjh[k mRrh.kZ djus dk o’kZ
Ldwy@dkWyst Name of rkjh[k Date of leaving Year of Passing
School/College with full Date of entering
address

…….. 3
 F-10
(3)
11. ;fn vki fdlh Hkh le; lsok esa jgs gSa] rks mldk fooj.k nsA
a
If you have, at any time, been employed, give details.
/kkfjr in dk uke] vof/k Period dk;kZy;] O;olk; lsok dks NksM+dj
fu’ikfnr dk;Z izfr’Bku ;k laLFkku tkus dh otg
Designation of
ls @ From rd @To dk iwjk irk Reasons for
post held of Full address of the leaving the job
description of Office, Firm or
work Institution

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;sx%sa &
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 ns]a
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 djs]a 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 ldsx
a hA

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 gw]a 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’; es½a 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