Date : ___________________

Staff Declaration Form Cluster : _________________

1. Name of The Candidate: __________________________________ Nick Name (If any): ______________ ___
2 Father's / Spouse Name: __________________________________
3 Permanent Address (With Contact Numbers):Vill/City:______________________________PO:______ ___________________________
_PS:______________________ Dist:________ __State:____ ____Pin:______ PH: ____ _____________
4 Present Address (With Landmark):Vill/City:__________________________________ PO:___________________________________
_PS:_______________________Dist:_______________ State:______________Pin______ PH:__________________________
5 Date of Birth (DD-MM-YYYY): ______________________________________
6 Religion: _________________________ Nationality: ____________________ _____
7 Pan Card No . Aadhar Card Voter Id
8 Marital Status : ____ _________________
9 Educational Qualification:
Name of the Institution /
SL No: Name of Examination Year of Grade / Percentage University
Passing Division Obtained

10 Work Experience (If any):

SL No: Company Name Designation Joining Date Leaving Date

11 Name of the two Referees (Along with contact details):

(i) __________________________________ Occupation : _______________________ Contact No. : ____________________
(ii) __________________________________ Occupation: _______________________ Contact No. : ____________________
12 Name of nearest Bandhan DSC : _______________________
13 Have you been referred by any Bandhan employee? Yes No
If Yes, then please share, Employee Name :______________________ Emp. No. : __________ Mobile No. : ______________
14 Do you have any relative working in Bandhan? If yes, please provide the name and the relationship

1. __________________________________ 2. __________________________________
15 Have you been subjected to any disciplinary proceedings by your previous Employer(s) at any time?
(if yes ,please give brief description of the case(s) and whether you were punished or
Yes No exonerated in a separate sheet)
16.Have you been proceeded against under any criminal, civil statutes?
(if yes ,please give brief description of the case(s) and whether you were punished or
Yes No exonerated in a separate sheet)
17. Is any civil and/or Criminal case pending against you in any Court of Law( if yes, please provide full particulars of the case in a separate sheet)
Declaration :
Above information which is written by my hand is true to the best of my knowledge and information.

Candidate Name: ______________________________ Candidate Signature: _____________________ Date: ______________

 Declaration

" I, ___________________________, hereby authorize Bandhan Bank Ltd, or any authorized agencies of the Bank, to obtain my Credit
Bureau Score/Rating, about me from any Consumer Reporting Agency and/or Bureau including Commercial Credit Agencies or
Bureaus".

" I, ___________________________, also hereby authorize Bandhan Bank Ltd, or any authorized agency of the bank, to conduct a
health check-up for myself through any of its empanelled centres to ascertain my health status to be able to continue my current job
role in the bank. The medical test shall be conducted before my confirmation in the job. I hereby affirm to abide by the decision of the
bank with regard to my continuance in the current job, based on the diagnosis.

I certify that the foregoing information and all the statements and declarations made by me are correct and complete to the best of
my knowledge and belief and no attempt has been made to conceal or withhold any pertinent information.Any falsification or
misrepresentation found in the aforesaid declarations,made by me ,I may be dismissed from the services of the Bank without any
notice or any compensation in lieu of notice and/or any action which the Bank may deem fir to initiate against me and I shall abide
by Bank's such decision.

I have/will have no objection to the bank making enquires at any time(immediately/in near future)regarding the statements and /or
decalarations made by me,in any manner the Bank decides to do inclusive of police enquiry into my antecedents.

______________ ____

Signature of the Candidate

For Office Use Only(Verification)

Check list to be Covered During Background Verification(BGV)

a) Name of the Candidate:

b) Present/Permanent Address Along with KYC to be Verified:

c) Vintage of the address:

d) Reputation in his Area (Good/Bad)

e) Educational Certificates Produced during Interview(True/False):

f) Source of Family earning:

g) Job Experience if any:

h) Do the Candidate’s Family have any Loan with Bandhan Bank (Yes/No):

Remarks of the Verifier: Remarks of HR Official:

Name of the Authorized Bank Official : Name of Authorised HR Official:

Employee ID: Employee ID :

Job Role : Job Role:

Workstation : Workstation :

Cluster :

__________________(Signature) ___________________ (Signature)