APPLICATION FORM FOR BUSINESS CORRESPONDENT
1. Name (IN BLOCK LETTERS) PHOTO
2. Father’s / Husband’s Name
3. Date of Birth and age
4. Gender (Please Tick) - □ Male □ Female
5. Marital Status (Please Tick) - □ Married □ Unmarried
6. Education (Please Tick) - □ Class X □ Class XII
- □ Graduate □ Post Graduate and above
7. Location (Village / Town) - Location
- District
- State
- PIN
8. Permanent Address
- P.O. Tehsil
- District
- State Pin :
9. Communication Address
- P.O. Tehsil
- District
- State Pin :
10. Telephone No. (with STD Code) - Residence
- Office
- Mobile
11. E-mail ID, if any -
12. Currently Banking with (Bank & Branch) -
13. Bank Account Number, if any -
14. Cheque Facility (Please Tick) - □ Available □ Not Available
15. Photo ID Proof (Please Tick and fill any one)
□ Driving License - Number :
□ PAN Card - Number :
□ Voter’s ID Card - Number :
□ Passport - Number :
□ Aadhaar Card - Number :
16.(a) Proof of address (Please Tick) –
□ Electricity Bill (Latest) □ NSC (Copy)
□ Telephone Bill (Latest) □ LIC Policy (Copy)
□ Letter from landlord □ Gas Connection
□ Aadhaar Card – Number :
16 (b) PAN NO.
17. Present Business /
Occupation, if any
18. Present monthly income (Please Tick):
□ Less than Rs.5000
□ Rs.5000 - Rs.10000
□ Rs.10000 - Rs.20000
□ Rs.20000 - Rs.30000
□ More than Rs.30000
19. Do you have any experience
in selling financial products?
If yes, give details.
20. Languages known (say fluent / not so fluent)
Read Write Speak
English
Hindi
Regional Language
(specify)
Any other (specify)
21. No. of years of stay in
the town / village In town In village
22. Do you have any adverse police records? If yes, give details.
23. Names, address and occupation :
of two people (not related to applicant)
to whom reference can be made.
24. Default if any to Banks / Financial Institutions (give details):
25. Infrastructure available: (Office, area, location, computer, Internet, Tel No. etc):
26.a. Name of the office from which retired.
(Applicable to retired Bank Employee)
26.b. Position at the time of retirement.
(Pl give brief of various positions held and role)
27. Any disciplinary action taken against you while in service
(if Yes, please give details. Please enclose a certificate of Conduct from your last
the employer)
28. Particulars of liabilities.
Type of liability Bank / Institution Branch A/c No. Amount
29. Particulars of movable property and Investments in the name of applicant:
30. Particulars of Immovable property in the name of applicant:
A) Land: Village Survey/Patta No B) House/ Flat Area
Location Built up area Year of construction
31. Are you willing to invest in the machine and other equipment required for
carrying out transactions as Business correspondents.
32. What is the cash balance you are ready to invest for making cash payments /
receipt of deposits as Business Correspondent.
33. Are you willing to provide a minimum deposit of Rs.50,000/- duly assigned to
the Bank as security:
34. Are you ready to take general insurance cover for a minimum of Rs. 50,000/-
on the cash balance to be held by you overnight and cash in transit:
I certify that the above information is true to the best of my knowledge and belief.
Date
Place. Signature of the applicant
Address & ID Proof *
* May be obtained from Sarpanch /Mukhiya /Gazatted Govt.
Servant / Post Master / Tahsildar / Police Inspector / Govt. Teacher
This is to certify that Mr. / Ms. / Mrs. ………………………………………… has been a 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) :
………………..……………………………………………………………………………………
References
1)
I hereby certify that …………………………… has been a resident of ……………………………...
Village / town of …………………..….…… district in …………………………… State of period of
… years and has been known to me for period of ……….. years.
(Signature)
Name of Referee ……………………………………………………………………………………………
Address: …………………………………………………………………………….………………………………..
………………………………………………………………………………………………………………
Designation / Title : …………………………………………………………………………………………
2)
I hereby certify that …………………………… has been a resident of ……………………………...
Village / town of …………………..….…… district in …………………………… State of period of
……….. years and has been known to me for period of ……….. years.
(Signature)
Name of Referee ……………………………………………………………………………………………
Address: …………………………………………………………………………….………………………………..
………………………………………………………………………………………………………………
Designation / Title : …………………………………………………………………………………………
