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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.

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 Certificate
7 Computer Literacy Certificates
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 Medical Fitness Report (At the Time of Reporting)

13 Satisfactory Report (From two Authority)

14 Discharge Certificate (For Ex-Servicemen)


15 ID Proof

16 CWE RRB V Score Card/ Mail Issued by IBPS

17 Passport Size Photograph Four

18 NOC issued by Present Employer

19 IBPS Application Form

20 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-9 Identity Form

F-10 Attestation Form

F-11
F-12
F-13

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 izfofV ,oa ckW;ksMsVk QkWeZ
SERVICE ENTRY CUM BIO-DATA FORM
1. (a) iwjk uke cM+s v{kjksa esa
Full Name (IN BLOCK LETTERS) : ______________________________________
(b) firk dk uke
Fathers 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. lsok xzg.k djus dh rkjh[k
Date of Joining Service : ______________________________________
6. inuke Designation : ______________________________________
7. Js.kh@osrueku Grade / Scale : ______________________________________
8. ifjokj ds lnL;ksa dk C;kSjk %
Details of family members :
uke fjrk mez vkfJr O;olk; dk ekfld osru
Name Relation Age Whether C;kSjk Salary per
dependent Details of month
(Y / N) occupation (Rs.)

9. igpku dk fpUg
Identification Mark : ______________________________________
10. D;k vki cSad ds fdlh funskd ;k deZpkjh
ds fjrsnkj gS \ ;fn gks] d`i;k ,sls O;fDr
dk iwjk C;kSjk] cSad esa mldh gSfl;r rFkk
D;k fjrk gS] ;g nkkZ,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.
11. ewy fuokl dk LFkku Place of Domicile : ______________________________________
12. vius kS{kf.kd dk;Zdky ds nkSjku ;fn
vkius dksbZ O;ogkfjd izfk{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)
13. D;k vkidks fdlh izdkku dk Js; feyk gS\
isilZ] ys[k bR;kfn ;fn gks] d`i;k C;kSjk nsAa
Have you any publication to your : ______________________________________
credit (Papers, articles, etc.) ? If so, ______________________________________
please give details. ______________________________________
14. D;k vki vkxs fdlh ikB~;e 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. ______________________________________
15. 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. _____________________________________
16. D;k vkius fonsk ;k=k dh gS@;fn gks]]
d`i;k mldk m)s;] vkids fonsk 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. ______________________________________
17. D;k vki dHkh fxjrkj 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; ?kksfkr 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.
18. vU; dksbZ lwpuk tks vki nsuk pkgsaA
Any other information you would like : ______________________________________
to give. ______________________________________
19. 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.

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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 ?kksfkr djrk gwWa] fd esjs mDr nksuksa izksQkWekZ esa nh tkudkjh lR; gS rFkk
esjh tkudkjh ,oe~ fookl 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 Banks 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 Baroda


Rajasthan Kshetriya Gramin 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/2016-17/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: _____________________

Fathers 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 : ________________________
_________________________________
_________________________________
BARODA RAJASTHAN KSHETRIYA GRAMIN BANK
(HEAD OFFICE : AJMER)

Medical Fitness Report Dated : __________

Full Name Shri / Smt. / Miss _____________________________________ S/o, W/o, D/o

______________________________________, address ____________________

_____________________________________________________________________

_____________________________________________________________________

age ______years, date of birth ____________, height ____________weight ________.

COMPLAINT
_________________________________________________________________________

_________________________________________________________________________

___________________________________________________ Throat ______________

Eyes ______________ Temperature __________________ Tongue ___________

Joints __________ Pulse ___________ Teeth ____________ Glands ___________

Resp ________ Respiratory system _____________

Circulatory system ______________________________________ Centro Urinary

system _______________________ Nervous system _________________________

Pregnancy ____________________ Identification Mark _________________________

Remarks (regarding fitness) _____________________________________________

_________________________________________________________________________

_________________________________________________________________

Dated : ___________ Signature of the Doctor


F-9
BARODA RAJASTHAN KSHETRIYA GRAMIN BANK
HEAD OFFICE: AJMER
IDENTITY FORM
Affix passport
1. Full Name: size photograph
2. Designation: duly attested

3. Qualification:
4. Fathers 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; ?kksfkr 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 cM+s v{kjksa esa miuke ds lkFk fy[ksa] SURNAME NAME
;fn dksbZ gS ;fn vkius fdlh Hkh Lrj ij dksbZ
uke ;k miuke tksM+k gS ;k NksM+k gS] rks d`I;k
mYys[k djsa
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 vFkkZr xkao] Fkkuk vkSj
ftyk ;k edku la- ykbu@LVhV @jksM vkSj
kgj Present address in full (i.e. Village,
Thane and District or House No. Lane/
Street/Road and Town)
3. d iwjk LFkk;h irk vFkkZr xkao Fkkuk vkSj
ftyk ;k edku la- ykbu@LVhV@jksM kgj
vkSj ftys dk eq[;ky; dk uke
(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.
[k vxj ewy :i ls Hkkjr ds vykok fdlh
vU; nsk ds fuoklh gSa] rks ml nsk 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 fuokl dh vof/k lfgr tgka vki fiNys ikap okksZa ds nkSjku ,d ls vf/kd
okksZa 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 vFkkZr xkao] iwoZorhZ dkWye esa mfYyf[kr
From To Fkkuk vkSj ftyk edku la[;k ds fy, LFkku ds ftyk eq[;ky; dk
ykbu@LVhV@jksM+ vkSj kgj 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 d firk dk iwjk uke miuke ds lkFk] ;fn dksbZ gks rks
(a) Fathers Name in full with alias, if any : _________________________________
[k orZeku Mkd irk
vxj e`R;q gks xbZ rks vafre irk : _________________________________
(b) Present Postal Address _________________________________
(If dead, give last address) __________________________________
_________________________________
x LFkk;h irk (c) Permanent Address : _________________________________
_________________________________
_________________________________
_________________________________
?k iskk (d) Profession : _________________________________
M- vxj lsok esa gS] rks inuke vkSj dk;kZy; irk : _________________________________
(e) If in service, give designation and _________________________________
official address _________________________________
5.2 d ifr@ifRu dk iwjk uke
(a) Spouses name in full : _________________________________
[k iskk
(b) Profession : _________________________________
x inuke vkSj dk;kZy; irk
(c) Designation and Office Address : _________________________________
_________________________________
_________________________________
6. ukxfjdrk @ Nationality of
d firk @(a) Father : _________________________________
[k ekWa @ (b) Mother : _________________________________
x ifr@ifRu (c) Spouse : _________________________________
7. ;FkkZr tUe frfFk Exact date of Birth : _________________________________
orZeku vk;q @ Present Age : _________________________________
eSVhd ds le; vk;q Age at Matriculation : _________________________________
8. d tUe LFkku (a) Place of Birth : _________________________________
ftyk vkSj jkT; tgak fLFkr gS
(Distt. & State in which situated) _________________________________
[k ftyk vkSj jkT; tgak ds jgus okys gks
(b) Distt. & State to which you belong : _________________________________
9. d vkidk /keZ (a) Your Religion : _________________________________
[k 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 fk{kk dk LFkku o okksZa ds lkFk Ldwy vkSj dkWyst
dk LFkku nkkZ;k x;k gksA
Educational qualifications showing place of education with years in Schools and
Colleges since 15th year of age.
iwjs irs ds lkFk izosk djus dh NksM+us dh rkjh[k mRrh.kZ djus dk okZ
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
fuikfnr dk;Z izfrBku ;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 fxjrkj 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 foofo|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] nksk flf)] n.Mknsk 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 d vFkok [k esa iwNs x;s iz'uksa ds
laca/k esa vkids mkj gk esa gks rks vkidks bl vuqizek.ku QkeZ Hkjrs le; ekeys] fxjrkjh] 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 &
ekad en gk@uk ;fn gk] rks fooj.k Hkh nsa
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 -@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 fxjrkj 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 fxjrkj 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 [kkRek 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 fookl 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; rqjar@fudV Hkfo; esa 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
BARODA RAJASTHAN KSHETRIYA GRAMIN BANK
(HEAD OFFICE : AJMER)
lsok izos k vfHkys[k
SERVICE ENTRY RECORD
d-dw-la- EC NO. ____________
1. iwjk uke cM+s v{kjks esa
Full Name (Block Letters) :_______________________________

2. firk dk uke
Fathers Name :_______________________________

3. tUe frfFk
Birth Date :_______________________________

4. lkek- vtk vttk vfio Hkw lS


(a) Gen SC ST OBC XSM
(b) PC OH HL VI %age

5. Religion / /keZ :_______________________________

6. v kS{kf.kd ;ksX;rk
(a) Academic Qualification + :_______________________________

c info ikB;e esa foksk fok;


(b) Subject of specialization :_______________________________
in Degree Course

7. iwoZ vuqHko ;fn gks


Previous experience (if any) :_______________________________

8. Hkkkkvksa dk Kku
Languages known

Hkkkk Language cksyuk Speak i<+uk Read fy[kuk Write


MARK ( ) MARK ( ) MARK ( )
1.
2.
3.

9. dk;Zxzg.k dh rkjh[k
Date of Joining Service :_______________________________

10. jkstxkj dk Lo:i ifjoh{kk


Nature of employment : Probation

11. inuke Designation :_______________________________

12. vkjfEHkd osru Starting Salary :_______________________________

13. igpku fpUg Identification marks :_______________________________

. 2
(2)

14. ifjp;nkrk 1-_______________________________


Introduced by (Names of Referee) : 2._______________________________

15. D;k vki cSad ds fdlh funskd vFkok vU;


deZpkjh ds laca/kh gS? ;fn gks rks mudk iwjk
uke rFkk laca/k dk mYys[k djsAa
Are you a relative of any Director :_______________________________
or the employee of the Bank ? If so, _______________________________
please state the full name of such a _______________________________
relative and the nature of relation. _______________________________

+ d`i;k foofo|ky; vFkok fudk; dk uke nsAa


+ Please state the name of the University or other body.

16. irk Address orZeku Present :_______________________________


_______________________________
_______________________________
_______________________________

LFkk;h Permanent :_______________________________


_______________________________
_______________________________
_______________________________

17. eksckbZy ua- Mobile No. :______________________________

18- bZ&esy E-Mail address :______________________________

19- vf/kokl LFkku Place of Domicile :_______________________________

20. gLrk{kj Signature :_______________________________

rkjh[k fooj.k lR;kfir


Date : ___________ Particulars verified

vf/kdkjh @Officer
d-dw-la- E.C.no.
(To be submitted at the time of joining by Office Assistant)
INDEMNITY BOND WITH SURETY
(To be stamped of Rs. 1000/- as per State Stamp Rules and Notarized)

This Indemnity is made and executed at ___________________ day of __________2017 by


Sh./Smt./Miss____________________________________________________________
Son/Daughter of Shri ___________________________________________________ a permanent
resident of _______________________________________________________
___________________________________________________________ hereinafter called
Selected candidate, the party of the First Part which expression shall unless repugnant to the
subject or context mean and include legal heirs, representatives and assigns, has been offered an
appointment for the post of Office Assistant (Multi-purpose) vide letter No. HO/2017-18/HRM/..........
dated . . . . . . . . . . . by the Employer Bank, i.e. Baroda Rajasthan Kshetriya Gramin Bank.
AND
Shri ______________________________________S/o Shri ______________________ a
permanent resident of _______________________________________________________
________________________________________________________________ hereinafter called
Surety, the party of the Second Part which expression shall unless repugnant to the subject or
context mean and include legal heirs, representatives and assigns, have at the request of the First
Part stand as Surety to the Financial Bond extended by First Part (Selected candidate) in favour of
Baroda Rajasthan Kshetriya Gramin Bank, a body corporate constituted under the Regional
Rural Banks Act, 1976 (21 of 1976), Regional Rural Banks amendment Act,2015 and Gazette
Notification dated 01.01.2013 issued by the Government of India, Ministry of Finance, Department
of Economic Affairs (Banking Division) having its Head Office at Ajmer hereinafter called Employer
Bank which expression shall unless repugnant to the subject or context shall mean and include
their successors, executors and administrators.
.2.

(2)
WHEREAS the Selected candidate has been selected for appointment as Office Assistant
(Multipurpose) in the service of the Employer Bank.
WHEREAS an Offer of Appointment containing the terms and conditions of the appointment
as Office Assistant (Multi-purpose) has already been issued to the Selected candidate
vide letter No. HO/2017-18/HRM/......... dated . . . . . . . .. of the Employer Bank.
WHEREAS the acceptance of the terms and conditions of the appointment has already
been communicated to the Employer Bank on dated ________________ by the Selected
candidate.
WHEREAS one of the terms and conditions of the appointment is that the Selected
candidate has to serve the Employer Bank i.e. Baroda Rajasthan Kshetriya Gramin
Bank for a minimum period of two years from the date of joining the bank service,
has to execute an indemnity with surety in favour of Employer Bank.
NOW THIS INDENTURE WITNESSETH as under:
1. In compliance of the aforesaid condition in the Offer of Appointment subject to
which the Employer Bank has agreed to give appointment to the Selected
candidate, the Selected candidate hereby undertakes to serve the Employer
Bank for a minimum period of two years.
2. The Selected Candidate agrees and undertakes, to indemnify the Employer Bank
that in case he/she commits breach of the above condition and resigns from or
leaves/abandons the service and/or neglects in performance of the duty assigned
to him leading to termination of his/her service as per Rules and Regulations by
the Employer Bank for all losses, costs, charges and expenses upto extent of Rs.
_____________ and pay an amount of Rs. __________ (Rs.
____________________________) only with the interest thereon @ 12 per cent
per annum from the date of breach of the above till payment as liquidated
damages/cost of training including on the job training, the expenses which the
Bank has incurred/may have to incur in recruiting another Selected Candidate at
his/her place, and also on account of business loss suffered/to be suffered by
Employer Bank during intervening period.
3. The party of the second part i.e. Sh.____________________________ S/o
Sh.___________________ agrees to stand as Surety for the due performance of
the obligation of the Selected Candidate under this agreement of indemnity.
4. The party of the Second Part undertakes and declares that he/she is having
satisfactory and adequate means, and stands as Surety for the due performance
of the obligation by the Selected Candidate under his bond. In case of breach of
the terms of this indemnity by the Selected Candidate and failure to indemnify the
Bank, to pay the amount of Rs. 1,00,000/- (Rs. one lac only) together with
interest thereon @ 12% per annum from the date of breach to Employer Bank
immediately on demand. The Surety shall be jointly and severally liable to pay the
aforesaid amount to the Employer Bank.
Contd..3
(3)

5. Notwithstanding anything contained herein above, furnishing of this indemnity will


not create any right in favour of the Selected Candidate to continue in the service
of Employer Bank for the aforesaid term of two years, and the Employer Bank
shall always have the right to take appropriate action against the Selected
candidate as per terms of the appointment letter and/or the Rules and
Regulations of the Employer Bank as applicable, in case of commission of any
misconduct by the Selected Candidate.
6. The amount specified above shall constitute a debt owing to the Employer Bank
and shall be recoverable from the Employee and the Surety jointly and severally
with interest thereon at the rate specified above till payment.
7. Apart from this indemnity, if the Selected candidate desire to leave the services of
the Bank, he will have to give one month notice under probation and after
confirmation three months notice to the Bank, failing which, Selected candidate
shall be liable to pay to the Employer Bank as compensation a sum equal to his
pay for the period of notice required.
Signed and delivered by the Party of the First Part i.e. the Employee having perused
and understood the contents terms of this Agreement .
Signed and delivered by the Party of the Second Part i.e. the Surety having perused and
understood the contents/terms of the Agreement.
IN WITNESS whereof, the Selected Candidate and the Surety have put their
signatures in the presence of the witnesses.

Photo of Signature of
Candidate Name :_____________________
& Signature
across

Photo of Signature of Surety


Surety Name :_____________________
& Signature
across

WITNESS: WITNESS:
1. Signature ___________________ 2. Signature ___________________
Name : ____________________ Name : ____________________
Son/Daughter of : _______________ Son/Daughter of : _______________
Full Address ___________________ Full Address ___________________
______________________________ ______________________________
Mobile No. _________________ Mobile No. _________________
(To be submitted at the time of joining By Officer)
INDEMNITY BOND WITH SURETY
(To be stamped of Rs. 2000/- as per State Stamp Rules and Notarized)
This Indemnity is made and executed at ___________________ day of __________2017 by
Sh./Smt./Miss____________________________________________________________
Son/Daughter of Shri ___________________________________________________ a permanent
resident of _______________________________________________________
___________________________________________________________ hereinafter called
Selected candidate, the party of the First Part which expression shall unless repugnant to the
subject or context mean and include legal heirs, representatives and assigns, has been offered an
appointment for the post of Officer Junior Management Scale-I vide letter No. HO/2017-18/
HRM/.............. dated . . . . . . . . . . . by the Employer Bank, i.e. Baroda Rajasthan Kshetriya
Gramin Bank. AND
Shri ______________________________________S/o Shri ______________________ a
permanent resident of _______________________________________________________
________________________________________________________________ hereinafter called
Surety, the party of the Second Part which expression shall unless repugnant to the subject or
context mean and include legal heirs, representatives and assigns, have at the request of the First
Part stand as Surety to the Financial Bond extended by First Part (Selected candidate) in favour of
Baroda Rajasthan Kshetriya Gramin Bank, a body corporate constituted under the Regional
Rural Banks Act, 1976 (21 of 1976) Regional Rural Banks amendment Act,2015 and Gazette
Notification dated 01.01.2013 issued by the Government of India, Ministry of Finance, Department
of Economic Affairs (Banking Division) having its Head Office at Ajmer hereinafter called Employer
Bank which expression shall unless repugnant to the subject or context shall mean and include
their successors, executors and administrators.
Contd..2.
(2)
WHEREAS the Selected candidate has been selected for appointment as Officer Junior
Management Scale-I in the service of the Employer Bank.

WHEREAS an Offer of Appointment containing the terms and conditions of the appointment as
Officer Junior Management Scale-I has already been issued to the Selected candidate vide letter
No. HO/2017-18/HRM/......... dated . . . . . . . . .. of the Employer Bank.

WHEREAS the acceptance of the terms and conditions of the appointment has already been
communicated to the Employer Bank on dated ________________ by the Selected candidate.

WHEREAS one of the terms and conditions of the appointment is that the Selected
candidate has to serve the Employer Bank i.e. Baroda Rajasthan Kshetriya Gramin Bank for
a minimum period of two years from the date of joining the bank service, has to execute an
indemnity with surety in favour of Employer Bank.

NOW THIS INDENTURE WITNESSETH as under:


1. In compliance of the aforesaid condition in the Offer of Appointment subject to which the
Employer Bank has agreed to give appointment to the Selected candidate, the Selected
candidate hereby undertakes to serve the Employer Bank for a minimum period of two
years.
2. The Selected Candidate agrees and undertakes, to indemnify the Employer Bank that in
case he/she commits breach of the above condition and resigns from or
leaves/abandons the service and/or neglects in performance of the duty assigned to him
leading to termination of his/her service as per Rules and Regulations by the Employer
Bank for all losses, costs, charges and expenses upto extent of Rs. _____________
and pay an amount of Rs. __________ (Rs. ____________________________) only
with the interest thereon @ 12 per cent per annum from the date of breach of the above
till payment as liquidated damages/cost of training including on the job training, the
expenses which the Bank has incurred/may have to incur in recruiting another Selected
Candidate at his/her place, and also on account of business loss suffered/to be suffered
by Employer Bank during intervening period.
3. The party of the second part i.e. Sh.____________________________ S/o
Sh.___________________ agrees to stand as Surety for the due performance of the
obligation of the Selected Candidate under this agreement of indemnity.
4. The party of the Second Part undertakes and declares that he/she is having satisfactory
and adequate means, and stands as Surety for the due performance of the obligation by
the Selected Candidate under his bond. In case of breach of the terms of this indemnity
by the Selected Candidate and failure to indemnify the Bank, to pay the amount of Rs.
2,00,000/- (Rs. Two lac only) together with interest thereon @ 12% per annum from the
date of breach to Employer Bank immediately on demand. The Surety shall be jointly
and severally liable to pay the aforesaid amount to the Employer Bank.
Contd..3.
(3)

5. Notwithstanding anything contained herein above, furnishing of this indemnity will not
create any right in favour of the Selected Candidate to continue in the service of
Employer Bank for the aforesaid term of two years, and the Employer Bank shall always
have the right to take appropriate action against the Selected candidate as per terms of
the appointment letter and/or the Rules and Regulations of the Employer Bank as
applicable, in case of commission of any misconduct by the Selected Candidate.
6. The amount specified above shall constitute a debt owing to the Employer Bank and
shall be recoverable from the Employee and the Surety jointly and severally with interest
thereon at the rate specified above till payment.
7. Apart from this indemnity, if the Selected candidate desire to leave the services of the
Bank, he will have to give one month notice under probation and after confirmation three
months notice to the Bank, failing which, Selected candidate shall be liable to pay to the
Employer Bank as compensation a sum equal to his pay for the period of notice required.
Signed and delivered by the Party of the First Part i.e. the Employee having perused and
understood the contents terms of this Agreement .
Signed and delivered by the Party of the Second Part i.e. the Surety having perused and
understood the contents/terms of the Agreement.
IN WITNESS whereof, the Selected Candidate and the Surety have put their signatures in the
presence of the witnesses.

Photo of Signature of
Candidate Name :_____________________
& Signature
across

Photo of Signature of Surety


Surety Name :_____________________
& Signature
across

WITNESS: WITNESS:
1. Signature ___________________ 2. Signature ___________________
Name : ____________________ Name : ____________________
Son/Daughter of : _______________ Son/Daughter of : _______________
Full Address ___________________ Full Address ___________________
______________________________ ______________________________
Mobile No. _________________ Mobile No. _________________
(To be submitted at the time of joining By Officer)
INDEMNITY BOND WITH SURETY
(To be stamped of Rs. 2000/- as per State Stamp Rules and Notarized)
This Indemnity is made and executed at ___________________ day of __________2017 by
Sh./Smt./Miss____________________________________________________________
Son/Daughter of Shri ___________________________________________________ a permanent
resident of _______________________________________________________
___________________________________________________________ hereinafter called
Selected candidate, the party of the First Part which expression shall unless repugnant to the
subject or context mean and include legal heirs, representatives and assigns, has been offered an
appointment for the post of Officer Middle Management Scale-II vide letter No. HO/2017-18/
HRM/.............. dated . . . . . . . . . . . by the Employer Bank, i.e. Baroda Rajasthan Kshetriya
Gramin Bank. AND
Shri ______________________________________S/o Shri ______________________ a
permanent resident of _______________________________________________________
________________________________________________________________ hereinafter called
Surety, the party of the Second Part which expression shall unless repugnant to the subject or
context mean and include legal heirs, representatives and assigns, have at the request of the First
Part stand as Surety to the Financial Bond extended by First Part (Selected candidate) in favour of
Baroda Rajasthan Kshetriya Gramin Bank, a body corporate constituted under the Regional
Rural Banks Act, 1976 (21 of 1976) Regional Rural Banks amendment Act,2015 and Gazette
Notification dated 01.01.2013 issued by the Government of India, Ministry of Finance, Department
of Economic Affairs (Banking Division) having its Head Office at Ajmer hereinafter called Employer
Bank which expression shall unless repugnant to the subject or context shall mean and include
their successors, executors and administrators.
Contd..2.
(2)
WHEREAS the Selected candidate has been selected for appointment as Officer Middle
Management Scale-II in the service of the Employer Bank.

WHEREAS an Offer of Appointment containing the terms and conditions of the appointment as
Officer Middle Management Scale-II has already been issued to the Selected candidate vide letter
No. HO/2017-18/HRM/......... dated . . . . . . . . .. of the Employer Bank.

WHEREAS the acceptance of the terms and conditions of the appointment has already been
communicated to the Employer Bank on dated ________________ by the Selected candidate.

WHEREAS one of the terms and conditions of the appointment is that the Selected
candidate has to serve the Employer Bank i.e. Baroda Rajasthan Kshetriya Gramin Bank for
a minimum period of two years from the date of joining the bank service, has to execute an
indemnity with surety in favour of Employer Bank.

NOW THIS INDENTURE WITNESSETH as under:


1. In compliance of the aforesaid condition in the Offer of Appointment subject to which the
Employer Bank has agreed to give appointment to the Selected candidate, the Selected
candidate hereby undertakes to serve the Employer Bank for a minimum period of two
years.
2. The Selected Candidate agrees and undertakes, to indemnify the Employer Bank that in
case he/she commits breach of the above condition and resigns from or
leaves/abandons the service and/or neglects in performance of the duty assigned to him
leading to termination of his/her service as per Rules and Regulations by the Employer
Bank for all losses, costs, charges and expenses upto extent of Rs. _____________
and pay an amount of Rs. __________ (Rs. ____________________________) only
with the interest thereon @ 12 per cent per annum from the date of breach of the above
till payment as liquidated damages/cost of training including on the job training, the
expenses which the Bank has incurred/may have to incur in recruiting another Selected
Candidate at his/her place, and also on account of business loss suffered/to be suffered
by Employer Bank during intervening period.
3. The party of the second part i.e. Sh.____________________________ S/o
Sh.___________________ agrees to stand as Surety for the due performance of the
obligation of the Selected Candidate under this agreement of indemnity.
4. The party of the Second Part undertakes and declares that he/she is having satisfactory
and adequate means, and stands as Surety for the due performance of the obligation by
the Selected Candidate under his bond. In case of breach of the terms of this indemnity
by the Selected Candidate and failure to indemnify the Bank, to pay the amount of Rs.
2,00,000/- (Rs. Two lac only) together with interest thereon @ 12% per annum from the
date of breach to Employer Bank immediately on demand. The Surety shall be jointly
and severally liable to pay the aforesaid amount to the Employer Bank.
Contd..3.
(3)

5. Notwithstanding anything contained herein above, furnishing of this indemnity will not
create any right in favour of the Selected Candidate to continue in the service of
Employer Bank for the aforesaid term of two years, and the Employer Bank shall always
have the right to take appropriate action against the Selected candidate as per terms of
the appointment letter and/or the Rules and Regulations of the Employer Bank as
applicable, in case of commission of any misconduct by the Selected Candidate.
6. The amount specified above shall constitute a debt owing to the Employer Bank and
shall be recoverable from the Employee and the Surety jointly and severally with interest
thereon at the rate specified above till payment.
7. Apart from this indemnity, if the Selected candidate desire to leave the services of the
Bank, he will have to give one month notice under probation and after confirmation three
months notice to the Bank, failing which, Selected candidate shall be liable to pay to the
Employer Bank as compensation a sum equal to his pay for the period of notice required.
Signed and delivered by the Party of the First Part i.e. the Employee having perused and
understood the contents terms of this Agreement .
Signed and delivered by the Party of the Second Part i.e. the Surety having perused and
understood the contents/terms of the Agreement.
IN WITNESS whereof, the Selected Candidate and the Surety have put their signatures in the
presence of the witnesses.

Photo of Signature of
Candidate Name :_____________________
& Signature
across

Photo of Signature of Surety


Surety Name :_____________________
& Signature
across

WITNESS: WITNESS:
1. Signature ___________________ 2. Signature ___________________
Name : ____________________ Name : ____________________
Son/Daughter of : _______________ Son/Daughter of : _______________
Full Address ___________________ Full Address ___________________
______________________________ ______________________________
Mobile No. _________________ Mobile No. _________________
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........................................ Photo
State..........................................Pincode...................................... (Self signed)
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 : ..................................................... Photo
Address : .............................................................................. (Self signed)
.............................................................................
..............................................................................

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

(Signature of the issuing Authority)


Official Seal
cM+kSnk jktLFkku {ks=h; xzkeh.k cSad
Baroda Rajasthan Kshetriya Gramin Bank
cSad vkWQ cM+kSnk }kjk izk;ksftr (Sponsored by Bank of Baroda)
uke & -------------------------------------------------- d-dw-la- -----------------------

ifjf'k"V&1 PPENDIX- fu;e 31 nsf[k, [Rule 3 (1)]

igyh fu;qfDr ij ;k 31 ekpZ] --------------------- dks ;Fkkfo|eku vkfLr;ksa vkSj nkf;Roksa dh fooj.kh
Return of Assets and Liabilities on first appointment or as on the 31st March ..
yksdiky vkSj yksdk;qDr vf/kfu;e] 2013 dh /kkjk 44 ds v/khu
(Under Sec 44 of the Lokpal and Likayuktas Act, 2013)

1- yksd lsod dk iwjk uke Li"V v{kjksa esa --------------------------------------------------------------


Name of the Public servant in full (in Block letters)
deZpkjh dk dksM la- bZ-lh- ua- -----------------------------------------------------------------------
2- d orZeku esa /kkfjr yksd fLFkfr --------------------------------------------------------------
(A) Present Public position held
inuke] uke vkSj laxBu dk irk & % in uke % -----------------------------------------------------------
(Designation , Name and address of cSad dk uke% cM+kSnk jktLFkku {ks=h; xzkeh.k cSad
organisation) 'kk[kk@dk;kZy; dk irk% ----------------------------------------------------------------
[k fdl lsok ls lEcfU/kr gSa ;fn ykxw gS cSad lsok
(B) Service to which belongs (If applicable)

?kks"k.kk (Declaration) &


;g ?kks"k.kk djrk gWwa fd yksdiky vkSj yksdk;qDr vf/kfu;e] 2013 dh /kkjk&44 ds micU/kksa ds v/khu] esjs }kjk
izLrqr dh tkus okyh lwpuk dh ckcr~ layXu fooj.kh vFkkZr~ izk:i 1 ls izk:i 4 esjs loksZRre Kku vkSj fo'okl
ds vuqlkj lR; vkSj Bhd gSA
I hereby declare that the return enclosed namely, forms I to IV are complete, true and correct to the best of my knowledge and
belief, in respect of information due to be furnished by me under the provisions of section 44 of the Lokpal and Lokayukts
Act 2013.

rkjh[k (Date) ---------------------------------------------- gLrk{kj (Signature) ---------------------------

*igyh fu;qDr dh n'kk esa] d`i;k fu;qfDr dh rkjh[k minf'kZr djsa % --------------------------------------
* (In case of first appointment please indicae date of appointment)
fVIi.k 1- bl fooj.kh esa ;k rks mlds Lo;a ds uke ;k fdlh vU; O;fDr ds uke yksd lsod dh lHkh vkfLr;ksa vkSj nkf;Roksa
dh fof'kf"V;ka varfoZ"V gksxhA fooj.kh esa yksdiky vkSj yksdk;qDr vf/kfu;e] 2013 dh /kkjk 44 2 esa ;Fkkmicaf/kr ifr ;k iRuh
vkSj vkfJr ckydksa dh vkfLr;ks@ a nkf;Roksa dh ckcr~ C;kSjs lfEefyr gksx
a sA
(/kkjk 442 yksd lsod ml rkjh[k ls ftldks og viuk inxzg.k djus ds fy, 'kiFk ysrk gS ;k izfrKku djrk gS] rhl fnu dh
vof/k ds Hkhrj l{ke izkf/kdkjh dks &&&&
d mu vkfLr;ksa ds lEcU/k esa ftudk og] mldk ifr ;k iRuh vkSj mlds vkfJr ckyd la;qDrr% ;k i`Fkdr% Lokeh ;k
Qk;nkxzkgh gS %
[k vius vkSj vius ifr ;k iRuh vkSj vius vkfJr ckydksa ds nkf;Roksa ds lEcU/k esa] lwpuk nsxkA
fVIi.k 2- ;fn dksbZ yksd lsod] ;k rks ^^drkZ^^ ;k fdlh lnL; ds :i esa dqVqac dh lEifRr;ksa esa lg leka'kh vf/kdkjksa ds lkFk
fgUnw vfoHkDr dqVqac dk lnL; gS rks mls ,sls lEifRr esa vius Hkkx dk ewY; izk:i la- 3 dh fooj.kh esa minf'kZr djuk pkfg,
vkSj tgka ,sls Hkkx dk Bhd ewY; minf'kZr djuk lEHko ugha gS] ogka bldk yxHkx ewY; minf'kZr gks] Li"Vhdj.k fVIif.k;ksa dks
tksM+k tk ldsxk] tgka dgha vko';drk gksA
fVIi.k 3- ^^vkfJr ckyd^^ ls ,sls iq= vkSj iqf=;ka vfHkizsr gSa ftuds ikl miktZu dk dksbZ i`Fkd lk/ku ugha gS vkSj os viuh
vkthfodk ds fy, iw.kZr% yksdlsod ij vkfJr gSaA uhps yksdiky vkSj yksdk;qDr vf/kfu;e 2013 dh /kkjk 443 dk Li"Vhdj.k
Note 3:-- "dependent children" means sons and dauthters who have no separate means of earning and are wholly dependent
on the public servant for their livelihood. (Explanation below Section 44 (3) of Lokpal and Lokayuktas Act 2013)
cM+kSnk jktLFkku {ks=h; xzkeh.k cSad
Baroda Rajasthan Kshetriya Gramin Bank
cSad vkWQ cM+kSnk }kjk izk;ksftr (Sponsored by Bank of Baroda)

uke & -------------------------------------------------- d-dw-la- -----------------------

ifjf'k"V&2 APPENDIX-II fu;e 31 nsf[k, [Rule 3 (1)]


izk:i la[;k 1 (FORM No.1)

yksdlsod] mlds ifr ;k iRuh vkSj vkfJr ckydksa ds C;kSjs


(Details of Public Servant, his/her spouse and dependent children)

D;k fooj.kh] mlds


/kkfjr yksd fLFkfr }kjk i`Fkd :i ls
e Qkby dh tkrh gS
uke Name ;k dksbZ gks Public
la[;k Position held, if any Whether return being
filed by him/her,
separately
1 Lo;a (Self)

2 ifr ;k iRuh
(spouse)
3 vkfJr&1
(dependent-1)
4 vkfJr&2
(Dependent-2)
5 vkfJr&3
(dependent-3)
6 vkfJr&4
(dependent-4)
*7 vkfJr&5
(dependent-5)

*vkSj iafDr tksMs+] ;fn vko';d gS


*(Add more rows, if necessary)

rkjh[k (Date) ---------------------------------------------- gLrk{kj (Signature)------------------------------


cM+kSnk jktLFkku {ks=h; xzkeh.k cSad
Baroda Rajasthan Kshetriya Gramin Bank
cSad vkWQ cM+kSnk }kjk izk;ksftr (Sponsored by Bank of Baroda)

uke & -------------------------------------------------- d-dw-la- -----------------------


izk:i la- 2 (FORM No. II)
igyh fu;qfDr ij ;k 31 ekpZ] ---------------------- dks ;Fkkfo|eku taxe lEifRr dk fooj.k
Statement of movable property on first appointment or as on the 31st March ..
Lo;a] ifr ;k iRuh vkSj vkfJr izR;sd ckyd ds fy, i`Fkd 'khV dk iz;ksx djsa
(Use separate sheets for self, spouse and each dependent child)
- fVIif.k;ka] ;fn dksbZ gksa
fooj.k (Particulars) jkf'k (Amount)
la- (Details/Remarks)
(i)* udnh vkSj cSad esa vfr'ks"k % Cash and bank balance udnh %
cSad 'ks"k%
(ii)* chek lanRr izhfe;e Insurance (premia paid):
fu;r@vkorhZ tek % Fixed/Recurring Deposit(s):
'ks;j ckWM% (Shares/Bonds
ikjLifjd fuf/k fuf/k;ka % Mutual Fund(s)
isa'ku Ldhe@Hkfo"; fuf/k Pension Scheme/Provident Fund
vU; fofu/kku] ;fn dskbZ gks% Other investment, if any
(iii) fdlh O;fDr ;k vfLrRo ftlds vUrxZr] QeZ] dEiuh U;kl vkfn Hkh
gS] dks fn;k x;k O;fDrxr _.k@vfHknk; ,Mokal vkSj _f.k;ksa ls
izkIr vU; izkfIr;ka vkSj jde ;FkkfLFkfr] nks ekl dk ewy osru ;k
,d yk[k :i;s ls vf/kd
Personal loans/advance given to any person or entity including firm,
company, trust etc. and other receivables from debtors and the amount
(exceeding two months basic pay or Rupees one lakh, as the case may be)
(iv) eksVj ;ku fuekZ.k] jftLVhdj.k la[;k] ; djus dk o"kZ vkSj lanRr
jde ds C;kSjs Motor Vehicles (Details of Make, registration number,
year of purchase and amount paid)
(v) vkHkw"k.k vuqekfur Hkkj lksuk cgqewY; jRu dh ckcr 10 xzke
vf/kd ;k de % pkanh dh ckcr 100 xzke vf/kd ;k de otu
Jewellery [Give details of approximate weight (plus or minus 10 xzke
gms. in respect of gold and precious stones: plus or minus 100 esa
gms in respect of silver)]
lksuk % Gold
pkanh % Silver
cgweYw ; /kkrq,a vkSj cgqewY; jRu % Precious metals and
precious stones:
fefJr ens%a Composite items
vuqekfur ewY; minf'kZr djsa (indicate approximate value)***
(vi) dksbZ vU; vkfLr % mijksDr (i) ls (v) ds vUrxZr u vkus okyh taxe
vkfLr;ksa ds C;kSjs nsa Any other assets [Give details of movable assets not
covered in (i) to (v) above]
d QuhZpj Furniture
[k fQDlpj Fixtures
x izkphu oLrq,a Antiques
?k jaxfp= isafVax Paintings
M bysDVkfud miLdj Electronic equipment
p vU; Others
cM+kSnk jktLFkku {ks=h; xzkeh.k cSad
Baroda Rajasthan Kshetriya Gramin Bank
cSad vkWQ cM+kSnk }kjk izk;ksftr (Sponsored by Bank of Baroda)

uke & -------------------------------------------------- d-dw-la- -----------------------

-2-
fdlh izn'kZ dh ckcr~ C;kSjs rHkh minf'kZr djsa ;fn ml fof'k"V izoxZ
vFkkZr~ QuhpZj] fQDlpj] bysDVkfud miLdj vkfn esa lfEefyr
fdlh fof'k"V vkfLr dk dqy orZeku ewY;] ;FkkfLFkfr] nks ekl ds ewy
osru ;k 1-00 yk[k :i, ls vf/kd gks
(Indicate the details of an asset, only if the total current value of any
particular assets in any particular category (e.g. furniture, fixtures,
electronic equipments, etc.) exceeds two months' basic pay of Rs. 1.00
lakh, as the case may be)

rkjh[k (Date) ---------------------------------------------- gLrk{kj (Signature)------------------------------

*fons'kh cSad cSadksa eas tekvksa ds C;kSjs i`Fkd ls fn, tk,axAs


Details of deposits in the foreign Bank(s) to be given separately.
**2 yk[k :i, ls vf/kd ds fofu/kkuksa O;fDrxr :i ls fjiksVZ fd, tk;sx
a As 2 yk[k :i, ls de ds
fofu/kku ,d lkFk fjiksVZ fd;k tk ldrk gSA
Investments above Rs. 2 lakhs to be reported individually, Investments below Rs. 2 lakhs may be reported together.
***igyh fooj.kh esa minf'kZr ewy; dks i'pkr~orhZ foojf.k;ksa esa iqujhf{kr djus dh vko';drk ugha gS]
tgka rd lqlaxr o"kZ ds nkSjku dskbZ ubZ la;qDr en vftZr ugha dh xbZ gks ;k fdUgha fo|eku enksa dk
fuiVkjk ugha fd;k x;k gksA
Value indicated in the first return need not be revised in subsequent returns as long as no new composite items had been
acquired or no existing items had been disposed off during the relevant year".
cM+kSnk jktLFkku {ks=h; xzkeh.k cSad
Baroda Rajasthan Kshetriya Gramin Bank
cSad vkWQ cM+kSnk }kjk izk;ksftr (Sponsored by Bank of Baroda)

uke & -------------------------------------------------- d-dw-la- -----------------------

izk:i la- 4 (FORM No. IV)

igyh fu;qfDr ij ;k 31 ekpZ --------------------------- dks ;Fkkfo|eku _.kksa vkSj vU; nkf;Roksa dk fooj.k
Statement of Debts and Other Liabilities on first appointment or as on 31st March ..

_.kh Lo;a@ifr ;k ysunkj dk uke _.k@nkf;Ro dh


-la- iRuh ;k vkfJr ckyd vkSj irk izd`fr vkSj jde fVIif.k;ka Remarks
Sl.No. Debtor (Self/Spouse or Name and address Nature of debt/
dependent children) Creditor liability and amount

rkjh[k (Date) ---------------------------------------------- gLrk{kj (Signature)------------------------------

fVIi.k 1 % m/kkjksa dh O;f"Vd enksa dks tks nks ekl ds ewy osru ls vf/kd ugha gS tgka ykxw gkas vkSj vU; n'kkvksa
esa 1-00 yk[k :i;s gSa] lfEefyr fd;s tkus tkus dh vko';drk ugha gSA
Note 1: Individual items of loans not exceeding two months basic pay (where applicable) and Rs. 1.00 lakh in other cases
need not be included.

fVIi.k 2 % fooj.k esa cSadks]a dEifu;ka] foRrh; laLFkvksa] dsUnzh; ljdkj@jkT; ljdkj ls vkSj O;f"V;ksa ls fy, x,
fofHkUu _.kksa vkSj vfHknk;ksa ,Mokalksa dks lfEefyr djuk gksxkA
Note 2. The statement should include various loans and advances (exceeding the value in Note 1) taken from banks,
complaints, financial institutions, Central /State Government and from individuals.