Application Format
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Baroda Rajasthan Gramin Bank Recruitment Project-2009 Application Format (Fill all columns in legible capital letters in his / her own handwriting and use 8.27" x 11.69" size paper - A4 size)
Information in first five columns viz. Post, Name, Father's Name, Address for communication and Permanent address must be filled in ENGLISH ONLY For Officers (Post Code-1)
For Clerk-cum-Cashier (Post Code-2)
To, Baroda Rajasthan Gramin Bank Recruitment Project-2009, Post Box No.7731, Borivali (West), MUMBAI - 400 092
To, Baroda Rajasthan Gramin Bank, Recruitment Project-2009, Post Box No.8591, Kandivali (East), MUMBAI - 400 101
Paste your recent passport size photograph and sign it across. Please retain with you three copies of the same photo for subsequent use
Dear Sir, With reference to Baroda Rajasthan Gramin Bank advertisement, I submit my application in the prescribed format :1.
A) Post applied : _________________________________ Code No.___________ B) Additional post applied _________________________ Code No.___________ Have you sent separate application with requisite fees and postage for other post also: YES / NO
2.
FULL NAME IN BLOCK LETTERS : (Leave one space blank between two parts of your name)
3.
FATHER'S / HUSBAND'S NAME IN BLOCK LETTERS : (Leave one space blank between two parts of your name)
4.
ADDRESS FOR COMMUNICATION (In Block letters) :
PIN
5.
PERMANENT ADDRESS (In Block letters) :
PIN
6.
Telephone No. with STD Code : Cell No. : E-mail address :
(2) 7.
Centre for Written Examination : (Please indicate by putting √ in the appropriate BOX)
Ajmer 8.
Bhilwara
Sawaimadhopur
Gender (Please indicate by putting √ in the appropriate BOX) Male
9.
Churu
Female
Category to which you belong (Please indicate by putting √ in the appropriate BOX) SC
ST
OBC
GENERAL
(Please attach attested photostat copy of Caste Certificate of SC/ST/OBC as applicable)
a. b. c.
Religion _________________ Sub-caste __________________ Name of the State/UT to which you belong : ________________ If Person With Disability (Please indicate by putting √ in the appropriate BOX) Orthopaedically Handicapped (OH)
Hearing Impaired (HI)
Visually Handicapped (VH)
Percentage of Disability : ________________________ d.
(Please attach attested photostat copy of medical certificate issued by Competent Authority) Are you eligible and intend to use the Service of Scribe? (Please indicate by putting √ in the appropriate BOX)
Yes
e.
No
Do you belong to Religious Minority : Yes
No
10. Are you an Ex-Serviceman ? Yes
No
If yes, specify the following i) Date of Discharge ii) Rank at present/last held a) Acting as b) Substantive
: : : :
_________________ _________________ _________________ w.e.f. _____________ _________________ w.e.f. _____________
11. Are you divorced / judicially separated ? Yes
No
12. Are you a candidate who had originally been domiciled in Kashmir Division of the State of J & K during the period of 01.01.1980 to 31.12.89. Yes
No
(3) 13. (a) Date of birth (As per School Leaving Certificate SSC/SSLC) Date
Month
Year
(b) Age as on 01.10.2009 : _______ Years ________ Months (c) Relaxation in Age (if claimed) : No. of Years _______ under Category ___________ 14. Nationality : __________________ 15. Details of Application fees and Postage charges : Name & address of Name & address of Issuing Bank / Drawee Bank / Branch Branch
Date of Issue Demand Draft / Amount Bankers in Rs. Cheque No.
(Application Fee should be sent in the form of Demand Draft in favour of "BRGB Recruitment Officers Project 2009" or "BRGB Recruitment Clerical Project 2009" as the case may be, payable at Ajmer only. Fees for General and OBC candidates is Rs.300/- and for SC/ST/PWD/EXS candidates is Rs.50/-.)
16. Pre-Examination Training (To be filled in only by those SC/ST/PWD/Religious Minority Community candidates, who are desirous of taking Pre-Examination Training)
Are you desirous of taking pre-examination training : (Please indicate by putting √ in the appropriate BOX) Yes
No
17. Place of Birth : Town/Village _______________ Tehsil _________________ District ________________
State _________________
18. Educational Qualification (From Class X onwards) (As on 01.10.2009) Examination Passed
Name of the Board / University
Subjects studied
Month & Year of passing
10th Std. 12th Std. Graduation Post Graduation
Others (If space is not sufficient please attach separate sheet).
19. Languages known. (Please indicate by putting √ in the appropriate BOX) S.No.
Language
Read
Write
Speak
% of Marks
Class / Division
(4) 20. Particulars of Post Qualification Experience including the Present Occupation / Job. Name of the employer(s) firm etc. and the nature and details of activities carried out by the employer
Designation and rank if any
Period of service
From
Length of service Years, Months, Days
Nature of duties performed in detail
Remarks (Reasons for leaving service)
To
21. Are you a native/domicile of Rajasthan? If yes, attach attested copy of domicile certificate. Yes
No
22. Any other information : _______________________________________________ _______________________________________________ 23. Before mailing application please check that you have furnished the following : a) b) c) d) e) f) g) h) i)
The post name and post code you have applied for. Category/Sub-category and have enclosed copies of necessary certificates for SC/ST/OBC/PWD/EXS candidates. Details regarding fees (Bank demand draft / Bankers Cheque) Address for communication. Separate application form with requisite fees for each post is sent. Details for claiming relaxation in age and the relevant certificate is enclosed. Two self-addressed unstamped envelopes of 11 x 5 size. An attested copy of Domicile Certificate is enclosed. The envelope is to be superscribed with the words "APPLICATION FOR THE POST OF _____________________, Post Code No. ____________, Baroda Rajasthan Gramin Bank Recruitment Project 2009"
DECLARATION I hereby declare that all the statements made in this application are true, complete and correct to the best of my knowledge and belief. I understand that in the event of any information being found false or incorrect at any stage or not satisfying the eligibility criteria according to the requirements of the relative advertisement, my candidature / appointment for the said post is liable to be cancelled / rejected at any stage and if appointed, my services are liable to be cancelled / terminated. I have not been debarred from taking up the test / selection by any Bank / IBPS and I have not been convicted in any criminal case. I am willing to serve any where, if selected. I agree that the Bank has the right to transfer me to any place at its discretion. I hereby agree that any legal proceedings in respect of any matter(s) or claims or disputes arising out of this application and / or out of the said advertisement can be instituted by me only before the Courts / Tribunals / Forums at Ajmer and they also shall have the sole and exclusive jurisdiction to try any case / dispute. I undertake to abide by all the terms & conditions mentioned in the advertisement given by the Bank and other further communication / intimation / notification with regard to this recruitment. Place : Date :
Signature of the Applicant
Information in first five columns viz. Post, Name, Father's Name, Address for communication and Permanent address must be filled in ENGLISH ONLY For Officers (Post Code-1)
For Clerk-cum-Cashier (Post Code-2)
To, Baroda Rajasthan Gramin Bank Recruitment Project-2009, Post Box No.7731, Borivali (West), MUMBAI - 400 092
To, Baroda Rajasthan Gramin Bank, Recruitment Project-2009, Post Box No.8591, Kandivali (East), MUMBAI - 400 101
Paste your recent passport size photograph and sign it across. Please retain with you three copies of the same photo for subsequent use
Dear Sir, With reference to Baroda Rajasthan Gramin Bank advertisement, I submit my application in the prescribed format :1.
A) Post applied : _________________________________ Code No.___________ B) Additional post applied _________________________ Code No.___________ Have you sent separate application with requisite fees and postage for other post also: YES / NO
2.
FULL NAME IN BLOCK LETTERS : (Leave one space blank between two parts of your name)
3.
FATHER'S / HUSBAND'S NAME IN BLOCK LETTERS : (Leave one space blank between two parts of your name)
4.
ADDRESS FOR COMMUNICATION (In Block letters) :
PIN
5.
PERMANENT ADDRESS (In Block letters) :
PIN
6.
Telephone No. with STD Code : Cell No. : E-mail address :
(2) 7.
Centre for Written Examination : (Please indicate by putting √ in the appropriate BOX)
Ajmer 8.
Bhilwara
Sawaimadhopur
Gender (Please indicate by putting √ in the appropriate BOX) Male
9.
Churu
Female
Category to which you belong (Please indicate by putting √ in the appropriate BOX) SC
ST
OBC
GENERAL
(Please attach attested photostat copy of Caste Certificate of SC/ST/OBC as applicable)
a. b. c.
Religion _________________ Sub-caste __________________ Name of the State/UT to which you belong : ________________ If Person With Disability (Please indicate by putting √ in the appropriate BOX) Orthopaedically Handicapped (OH)
Hearing Impaired (HI)
Visually Handicapped (VH)
Percentage of Disability : ________________________ d.
(Please attach attested photostat copy of medical certificate issued by Competent Authority) Are you eligible and intend to use the Service of Scribe? (Please indicate by putting √ in the appropriate BOX)
Yes
e.
No
Do you belong to Religious Minority : Yes
No
10. Are you an Ex-Serviceman ? Yes
No
If yes, specify the following i) Date of Discharge ii) Rank at present/last held a) Acting as b) Substantive
: : : :
_________________ _________________ _________________ w.e.f. _____________ _________________ w.e.f. _____________
11. Are you divorced / judicially separated ? Yes
No
12. Are you a candidate who had originally been domiciled in Kashmir Division of the State of J & K during the period of 01.01.1980 to 31.12.89. Yes
No
(3) 13. (a) Date of birth (As per School Leaving Certificate SSC/SSLC) Date
Month
Year
(b) Age as on 01.10.2009 : _______ Years ________ Months (c) Relaxation in Age (if claimed) : No. of Years _______ under Category ___________ 14. Nationality : __________________ 15. Details of Application fees and Postage charges : Name & address of Name & address of Issuing Bank / Drawee Bank / Branch Branch
Date of Issue Demand Draft / Amount Bankers in Rs. Cheque No.
(Application Fee should be sent in the form of Demand Draft in favour of "BRGB Recruitment Officers Project 2009" or "BRGB Recruitment Clerical Project 2009" as the case may be, payable at Ajmer only. Fees for General and OBC candidates is Rs.300/- and for SC/ST/PWD/EXS candidates is Rs.50/-.)
16. Pre-Examination Training (To be filled in only by those SC/ST/PWD/Religious Minority Community candidates, who are desirous of taking Pre-Examination Training)
Are you desirous of taking pre-examination training : (Please indicate by putting √ in the appropriate BOX) Yes
No
17. Place of Birth : Town/Village _______________ Tehsil _________________ District ________________
State _________________
18. Educational Qualification (From Class X onwards) (As on 01.10.2009) Examination Passed
Name of the Board / University
Subjects studied
Month & Year of passing
10th Std. 12th Std. Graduation Post Graduation
Others (If space is not sufficient please attach separate sheet).
19. Languages known. (Please indicate by putting √ in the appropriate BOX) S.No.
Language
Read
Write
Speak
% of Marks
Class / Division
(4) 20. Particulars of Post Qualification Experience including the Present Occupation / Job. Name of the employer(s) firm etc. and the nature and details of activities carried out by the employer
Designation and rank if any
Period of service
From
Length of service Years, Months, Days
Nature of duties performed in detail
Remarks (Reasons for leaving service)
To
21. Are you a native/domicile of Rajasthan? If yes, attach attested copy of domicile certificate. Yes
No
22. Any other information : _______________________________________________ _______________________________________________ 23. Before mailing application please check that you have furnished the following : a) b) c) d) e) f) g) h) i)
The post name and post code you have applied for. Category/Sub-category and have enclosed copies of necessary certificates for SC/ST/OBC/PWD/EXS candidates. Details regarding fees (Bank demand draft / Bankers Cheque) Address for communication. Separate application form with requisite fees for each post is sent. Details for claiming relaxation in age and the relevant certificate is enclosed. Two self-addressed unstamped envelopes of 11 x 5 size. An attested copy of Domicile Certificate is enclosed. The envelope is to be superscribed with the words "APPLICATION FOR THE POST OF _____________________, Post Code No. ____________, Baroda Rajasthan Gramin Bank Recruitment Project 2009"
DECLARATION I hereby declare that all the statements made in this application are true, complete and correct to the best of my knowledge and belief. I understand that in the event of any information being found false or incorrect at any stage or not satisfying the eligibility criteria according to the requirements of the relative advertisement, my candidature / appointment for the said post is liable to be cancelled / rejected at any stage and if appointed, my services are liable to be cancelled / terminated. I have not been debarred from taking up the test / selection by any Bank / IBPS and I have not been convicted in any criminal case. I am willing to serve any where, if selected. I agree that the Bank has the right to transfer me to any place at its discretion. I hereby agree that any legal proceedings in respect of any matter(s) or claims or disputes arising out of this application and / or out of the said advertisement can be instituted by me only before the Courts / Tribunals / Forums at Ajmer and they also shall have the sole and exclusive jurisdiction to try any case / dispute. I undertake to abide by all the terms & conditions mentioned in the advertisement given by the Bank and other further communication / intimation / notification with regard to this recruitment. Place : Date :
Signature of the Applicant
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