ALANKIT LIMITED

BCA APPLICATION FORM

Link Branch Name Link Branch Code

Photo
CSP Infra Available PC Printer Internet UPS

CSP Infra Available Own Rented Shared Punchyati

CSP Name (IN BLOCK LETTERS)

Father's / Husband's Name

Date of Birth Age

DD MM YYYY

Male Female Marital Status Married Unmarried

Gender

Educational Qualification 10+2 Graduate Post Graduate Above

CSP Permanent Address VPO

Landmark

Tehsil Distt.

State Pin Code

Contact Number Residence Office

Email ID

KIOSK Address Office Name

VPO

Landmark

Tehsil Distt.

State Pin Code

Bank Details (Only SBI) Bank Name

Bank A/c Number

Proof of ID Aadhar Card Pan Card Driving License Votar Card

Proof of Address Aadhar Card Pan Card Driving License Votar Card
Present Business/ Occupation (If Any)

Income per Month Less than Rs. 5,000 Rs. 5,001 - Rs. 10,000 Rs. 10,001 - Rs. 20,000

Rs. 20,001 - Rs. 50,000 More than Rs. 50,000

No. of years of stay in Town/ Village (In Years)

Outlet Profile Chemist Shop Telecom Shop Tour & Travel Shop Property Dealer

Cyber Cafe Petrol Pump Others

I certify that the above information is true to the best of my knowledge and belief.

Date : Applicant
Signature

Reference 1 Name

Address

Reference 1
Signature

Mobile

Reference 2 Name

Address

Reference 2
Signature

Mobile
 Attestation
Photo

May be obtained from Sarpanch / Mukhiya / Gazatted Govt. Servant/ Post

Master / Tahsildar / Police Inspector / Govt. Teacher

This is to certify That Mr./Ms./Mrs. …………………………………………………………………………………….had been

resident of (Complete Address)

…………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………

……………………….. For ………………………………………………………………..Years and holds a good character in the

area. His photograph is herewith attested and I confirm the same. His date of Birth is ………………...............

(Signature)

Name:-…………………………………………………………………………………………………………………………………………….

Address:-………………………………………………………………………………………………………………………………………….

Designation (with seal):- …………………………………………………………………………………………………………………