official website of bihar state madrasa education board, patna

1
LUilEX$Btu3ft!$rsgl rfi$u*[ft Irsffiffi-l L,.-**-J l@-!-F{**l rx.xq L$t{EFrrE _ J i.*"" CONSEtIT-CuFil. D€CIARATION FORf,I Cta:n liil{tln lrf,ra,rrl*r"i roi#f*Fe,qcfnntqq{tc{ afF Ar 0q?0l$ ----- I hereby give rny consent tc become a member ol'Pradhan Manhi Jeevan Jyoli Binra Ycjana' of itUanre oi Insuror) which $dl} bA #rnln*sM,by y+wBank und*r Master Policy I't*. iTa b+ pr+pnnted) i heret{ auftoire you lo &bil my Savings Sank Accainl wilir your Sranch with P*.330i- {Ruoees ?i"rree Hufldred Thirly &rfy} pfus $ervrbe lax il appliesble tonanJs premium oi lib cowr under FMJJBY. | fudhcir autirorize you to deduel rtr fuhrr* *ter lSs May and ncn laler then {s} 1'l of ,.lune €vefy }s*r until furliTer hs*uctions, air am0unl ol Rs.330l- {Rupees L\re€ hundrgd ltrirg mry} and *|Ylq.taX.ilfllgab1a'6f*l?Y.a#ts$$ta$'ded'{ie{fotn:tmai*.{imu,'itlrich.rca,l$ginlinatsd.ir*rngdiattlyt{andudtgEr$#, hwards rene.wd of cover*ge under lhe scherne. |lav*ptautlao*:ed**yo1l.l*rbsnkbds44tpreniunii0f*$f}ee|uftrhilsu|te*u;fe***ar+faat.rr.y.lif**ev.*rdabr#M{o *$.l,ffirffi#"o$$i*t*ermntdrny, a1h, i harre read and urd6r$o0d tre Sefrerie rugs and I'hereby gtve my consrnl to becorne a memkr af the $chenre. I trn svrar€,thA! tle:rlShq!}#o E*rdi{*rtq*3jqglFf6t 4$ dpvs,f{utn,hs:.dele $f ni*$mqt jtil+,{ft#.eelra{}}s {l&n3#bd) png in sasel Eblesft {otler than due to accidgr$ duri$g liq@ i a$$4ieq:$$,8*rit *:.cc*vey n}? p*r.wrat **iail$i $ivs,rJ belaw. as r*guir*d, resardi$S my admissicn lrrb,,lhs groilB iawrda0e *chemerb ...... -.... $ianr**f insurgr,) Arnlkant Oetails. rt Der8ank I KYC records: Sgiilg3f_q9ffi"$fip_4e{.{9_qper,$qnhr-e-qsrdsJ_ i sv*msEjrfrdfrfi'$,.'i*'.""-:'-*.*-'Racnarllunutri'iiavaiteb|e $'nail ld i I Mobile l{o. i ,ui:+in&i*;.:;uy:,i&;i,---i..-,......,s *.*.*-,-."-*",+.:+lt.;;,iJJ..;;..:.;:.,:_;,i;.:..:*.J_::"--.-.-_...-,,.....J $'nail ld i I Mobile l{o. i Ffi$e'{,#aiisd;f*".^--i**'."-**i1'Jf"6ia#icss;i rela{ar::sh!0,$iang of i I {if ilominee i$ fl}incri i aod,nines i i ' i Atidress ; l,her*Fy nomlna$ ,&bsv$ u$dsi lii$ sh&n& l&yn*ree king minw. his I her guarUirn 16 appoinied as abcvs. l'hereby dedare tfretthe:above statsmenls are lflre ifi ag ro$pects and lhat I agree and dedare fllat lh€ abow irr&rautrol'r tha$ fo*n &edie.e|d|nissio?}.tathgabsse-$*q*.'€adt'tat.i'.$1i,inlanrra1ion.be6$n$.u'1i^us,mfnteilei$l{lpib.tre.$stw#& teated as cancelle<l. 0ulc *-, $Sn$iffi$ r/sritidd f$Alclt O.n*ati t&n*hii$,urlr: AssnfiB$'$.|!{affi$- Aqenr:ylBC Code N$.' Eafik.S\is dst*$6 of Ag{$itl8C Slonature of Aoent8ankinc Cones*ondent' Signalur* Addres*: we hs''€by 66*flo$f€dgs f,s$eipl,of .cc0*sfit-sum"0eclaration F0rfff fsm sb I smt. ..;..,....!i..........!........,..-.... hosa4s 8ffrk Accetln{Nc'...'.AadhafNo'"..,.,,.",can*entlngand*tis,twki*Eauh*d*bi**tgt,t. Bsnt Ariou$t ts join tho Pradlran M**trj Jeavan Jyoli Simf Yqans n'ith .*:"****.- (Nafi6 of tlro lnsurance Compa*y| br mver ufidet Ma$er foiky,6s"..,... wnsiijeralion amcunl- st *3.6mtrrffi ;#4:r1${fie*f #S*;qf-,'cjg!,

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Page 1: Official Website of Bihar State Madrasa Education Board, Patna

LUilEX$Btu3ft!$rsgl

rfi$u*[ftIrsffiffi-lL,.-**-J

l@-!-F{**l rx.xqL$t{EFrrE _ J i.*""

CONSEtIT-CuFil. D€CIARATION FORf,I

Cta:n liil{tln lrf,ra,rrl*r"i roi#f*Fe,qcfnntqq{tc{ afF Ar 0q?0l$-----

I hereby give rny consent tc become a member ol'Pradhan Manhi Jeevan Jyoli Binra Ycjana' of itUanre oi Insuror) which$dl} bA #rnln*sM,by y+wBank und*r Master Policy I't*. iTa b+ pr+pnnted)

i heret{ auftoire you lo &bil my Savings Sank Accainl wilir your Sranch with P*.330i- {Ruoees ?i"rree Hufldred Thirly &rfy} pfus

$ervrbe lax il appliesble tonanJs premium oi lib cowr under FMJJBY. | fudhcir autirorize you to deduel rtr fuhrr* *ter lSs May andncn laler then {s} 1'l of ,.lune €vefy }s*r until furliTer hs*uctions, air am0unl ol Rs.330l- {Rupees L\re€ hundrgd ltrirg mry} and

*|Ylq.taX.ilfllgab1a'6f*l?Y.a#ts$$ta$'ded'{ie{fotn:tmai*.{imu,'itlrich.rca,l$ginlinatsd.ir*rngdiattlyt{andudtgEr$#,hwards rene.wd of cover*ge under lhe scherne.

|lav*ptautlao*:ed**yo1l.l*rbsnkbds44tpreniunii0f*$f}ee|uftrhilsu|te*u;fe***ar+faat.rr.y.lif**ev.*rdabr#M{o*$.l,ffirffi#"o$$i*t*ermntdrny, a1h,

i harre read and urd6r$o0d tre Sefrerie rugs and I'hereby gtve my consrnl to becorne a memkr af the $chenre. I trn svrar€,thA!tle:rlShq!}#o E*rdi{*rtq*3jqglFf6t 4$ dpvs,f{utn,hs:.dele $f ni*$mqt jtil+,{ft#.eelra{}}s {l&n3#bd) png in sasel

Eblesft {otler than due to accidgr$ duri$g liq@i a$$4ieq:$$,8*rit *:.cc*vey n}? p*r.wrat **iail$i $ivs,rJ belaw. as r*guir*d, resardi$S my admissicn lrrb,,lhs groilB iawrda0e*chemerb ...... -.... $ianr**f insurgr,)

Arnlkant Oetails. rt Der8ank I KYC records:

Sgiilg3f_q9ffi"$fip_4e{.{9_qper,$qnhr-e-qsrdsJ_ i

sv*msEjrfrdfrfi'$,.'i*'.""-:'-*.*-'Racnarllunutri'iiavaiteb|e$'nail ld i I Mobile l{o. i

,ui:+in&i*;.:;uy:,i&;i,---i..-,......,s *.*.*-,-."-*",+.:+lt.;;,iJJ..;;..:.;:.,:_;,i;.:..:*.J_::"--.-.-_...-,,.....J$'nail ld i I Mobile l{o. i

Ffi$e'{,#aiisd;f*".^--i**'."-**i1'Jf"6ia#icss;irela{ar::sh!0,$iang of i I {if ilominee i$ fl}incri

iaod,nines i i 'i Atidress ;

l,her*Fy nomlna$ ,&bsv$ u$dsi lii$ sh&n&l&yn*ree king minw. his I her guarUirn 16 appoinied as abcvs.

l'hereby dedare tfretthe:above statsmenls are lflre ifi ag ro$pects and lhat I agree and dedare fllat lh€ abow irr&rautrol'r tha$ fo*n&edie.e|d|nissio?}.tathgabsse-$*q*.'€adt'tat.i'.$1i,inlanrra1ion.be6$n$.u'1i^us,mfnteilei$l{lpib.tre.$stw#&teated as cancelle<l.

0ulc *-,

$Sn$iffi$ r/sritidd

f$Alclt O.n*ati t&n*hii$,urlr:

AssnfiB$'$.|!{affi$- Aqenr:ylBC Code N$.'Eafik.S\is dst*$6 of Ag{$itl8C

Slonature of Aoent8ankinc Cones*ondent'

Signalur*Addres*:

we hs''€by 66*flo$f€dgs f,s$eipl,of .cc0*sfit-sum"0eclaration F0rfff fsm sb I smt. ..;..,....!i..........!........,..-.... hosa4s 8ffrk

Accetln{Nc'...'.AadhafNo'"..,.,,.",can*entlngand*tis,twki*Eauh*d*bi**tgt,t.Bsnt Ariou$t ts join tho Pradlran M**trj Jeavan Jyoli Simf Yqans n'ith .*:"****.- (Nafi6 of tlro lnsurance Compa*y| br mverufidet Ma$er foiky,6s"..,...wnsiijeralion amcunl-

st *3.6mtrrffi ;#4:r1${fie*f #S*;qf-,'cjg!,