APPLICATION FOR EMPANELMENT OF

HOME LOAN COUNSELORS (HLCs) & DIRECT SELLING AGENTS (DSAs)

(RETIRED STAFF FROM THE BANK and PUBLI C/GROUPS/FIRMS/ COMP ANI ES)

To,

The Zonal Manager,

Indian Bank,
Zonal Office,
________________________

Sir/Madam,

I submit here with my application for the post of DSA in Indian Bank. I have read the
Role, Remuneration and Terms & Conditions relating to the service and advice that
they are acceptable to me.
1. Full Name Shri / Smt /
Kum (in Block Letters, as Mr./Mrs./Ms.___________________________
per degree certificate)
2. Father’s/Husband’s
Name
3. Constitution (Retd. Staff /
Individual / Firm /
Company)
4. In case of firm/company, Name of representative
the representative’s KYC
particulars to be
submitted separately
5. Candidates address Address
whe re he /she nor ma lly
resides/ will reside
where from he/she will
perform his/her duties
after selection (IN
BLOCKLETTERS)
District

State

Pincode Phone with STD

Mobile No.

Date of Birth D D M M Y Y Y Y
Age* (as on 30/09/2017)
D D M M Y Y Y Y
6. *should not be more than
65 years as on the
stipulated date. _____ years
7. Category
(SC/ST/OBC/GEN)
8. Educational Qualification
9. Present Occupation
10. Present Income
11. No. of years in
Employment
12. Last 3 Assignments held
covering minimum 5 Assignment From To Employer
years Name &
Address

13. Details of the Assets Total Asset in lakhs - Rs.__________________

14. Details of the Liabilities
Total Liabilities in lakhs – Rs.________________
(Detailed A&L as per format – enclosed)
15. PAN
16. Languages Known (Mark““in the appropriate box)
Language Read Write Speak Understand
a) [ ] [ ] [ ] [ ]

b) [ ] [ ] [ ] [ ]

c) [ ] [ ] [ ] [ ]

17. Reference (Name, 1.

Address & Contact No.)

2.
18. For Retired Indian Bank SR No.:
Employees 1. P.F. Index No:

2. Date of Retirement D D M M Y Y Y Y

3. Name of the IFS C Code

number Branch / Office
from where retired
4. Name of the IFS C Code
no . Branch / Office
where from rec eiving
Pension

I declare that all statement made in this application and the document submitted (as
per the list given below) are true, complete and correct to the best of my knowledge
and belief. I understand that in the event of any information being found untrue or
incorrect at any stage of my not satisfying any of the eligibility criteria according to
Indian Bank, my candidature is liable to be cancelled.

Place:

Date: Signature

Documents to be submitted :

Enclose the self- attested copied of following document along with my above
application and shall submit further documents required if any.
In general
1. PAN Card
2. Voter ID Card / Aadhaar Card (Address Proof)
3. Bank Statement for last 6 months
4. Educational Qualification (Proof)
5. Empanelment Letters of Other Bank / FIs / Experience Certificate if any
6. I T Returns, if applicable
7. Firm registration / incorporation / constitution letters
8. Net worth detail proofs
9. Two recent passport size photo
10. Asset and Liabilities Statement (format enclosed)

Exclusive for Retired Indian Bank Employees

11. ID card
12. Copy of the Pension Book
 DETAILS OF ASSETS AND LIABILITIES
OF____________________________________________________ AS ON

Address:_____________________________________________________________________________________

____________________________________________________________________________________________
IMMOVABLE PROPERTY
Lands
Name of the village Ancestral of If encumbered Extent in acres Market Value Total value
or Taluka Self acquired To what extent Wet/Dry Per acre Rs
Where the lands
are situated with
S.No

(1) Total Rs
Buildings
Name of the village Ancestral or If Market Value Total Value
or Town where they are Self- encumbered Rs.
situated and the street & acquired. To what
Municipal No: Extent.
Residential
House
Shops and
factories
Machinery/
Vehicles etc
(2) Total
Liquid Assets
Nature of If encumbered Amount Market Total Value
stock To what extent Value Rs.
Cash & Bank Balance
Investment in business
Investment in Government
Promissory Notes, shares,
NSC Etc
Other movable property like
Life Policy etc. (Paid up
value)
(State their nature)
(3) Total Rs
(1)+(2)+(3) Grand Total of Assets Rs
Liabilities
Borrowing SECURITY

Nature Value Limit Amount borrowing

Rs
From our Bank*
From other Bank*
From other sources*

Declared Net Income for the year 20__ - __ : Rs._________________

(Proof to be submitted)

I certify that all information furnished above is true. I have no borrowing except those mentioned above. No legal
action has been taken or pending in any court against me/us/firm/company. I am not in the defaulters list of
RBI/SAL of ECGC. I am not directors on board of any Public/Private sector/Co-operative Banks.

Date: Signature
 Investment in Business
Name of the Company/Firm Amount invested Amount withdrawn Net investment.

*Borrowings from our Bank

Name of the branch Nature of facility Limit sanctioned Security value (Rs) Balance outstanding
(Rs)

*Borrowing from other Banks

Name of the Bank Name of branch Nature of facility Amount Sanctioned Balance outstanding
(Rs) (Rs) (Rs)

*Contingent Liabilities
Name of facility Details of Liability Amount (Rs)
1.Guarantees signed

2.Taxes under dispute outstanding

3.Claim against us, not

acknowledged as debts

4.Bills discounted with Banker not yet

due for payment

5. Letters of Credits/Guarantees
issued on my behalf.

6. Estimated amount of contracts

remaining to be executed as capital
account not provided for.

7. Others, if any.
Total Rs

DATE: Signature
Details to be enclosed: IT/WT returns/ Balance Sheet/P&L