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SUTLEJ GRAMIN BANKH.O. A-4 CIVIL LINES, BATHINDA

PHONE NO.0164-2212885 FAX.0164-2212132Ref: RRB/2015/ Date:

1. Full Name (in Block Letters)______________________________________2. Designation _____________________________________________3. Academic & Vocational qualifications _____________________________________4. Father’s Name & Occupation ___________________________________________5. Caste ____________ Religion _______________ Marital status ______________If married, name of spouse______ Age ______________ & Children(s) __________________________________________________ & their age ________________6. Permanent Address ___________________________________________7. Present Address ____________________________________________________8. Place of Domicile, City _________________ State _______________________9. Date of Birth _________________ 10. Height _____________________ Cms11. Marks of identification: _______________________________________a) Colour _____________________________________b) Built (Thin/Medium/Heavy) ______________________________c) Any peculiarity in appearance, speech _________________________________12. Relationship with any employee or Director of the Bank (give name & address in vernacular)_________________________________________________________.13. Date of appointment with pay _________________________________________14. Date of signing photograph __________________________________________15. Left/Right hand thumb impression______________________________________16. Signature of the employee ___________________________________________17. Initials of the employee ______________________________________________Place: ___________Dated: __________


PHONE NO.0164-2212885 FAX.0164-2212132Ref: RRB/2015/ Date:

PROFORMA OF DECLARATION IN RESPECT OF EDUCATIONAL QUALIFICATION TO BE SUBMITTED BY EACH CANDIDATE FOR THE BANK’S SERVICE

1.____________________ Son/ Daughter / Wife of__________________________ do hereby declare that the requisite Educational Qualification as shown in my application is correct and complete and that I have not concealed anything in respect of my Educational Qualification I possess.I also declare I have passed the requisite Qualification prescribed for the post from the Board/University /Institute recognized by Govt. of India.

Further, I have passed_________________________________Examination/Degree from ____________________________________Board/University/Institute which is a .........................................(Autinomous Govt.) with ___________Division/class with___percentage of marks in aggregate in the year ______.If it is subsequently found out at any stage that I have concealed the fact and in the event even if I have been selected/appointed, I shall be liable to be dismissed from the Bank’s Service forthwith. ____________________________ Place: (Signature of the Candidate) Date: Name: Post: Roll No.:


PHONE NO.0164-2212885 FAX.0164-2212132

JOINING REPORT PROFORMA The General Manager DATED: Sutlej Gramin BankH/O Bathinda.

Dear Sir, REG: JOINING REPORTWith reference to HO, Bathinda letter no.___________dt______________, I hereby submit my joining report. My brief particulars are as follows:-1.Name_________________________2.Roll No.___________________________3.Date of joining:_______________before noon/afternoon4.Basic Pay:_____________Sp.All._________FPA:_____________PQA:______________

Yours faithfully ________________Name:______________________Post:________________________Roll No.___________________

The Chairman.Sutlej Gramin Bank,Head Office, A-4, Civil Lines,BathindaI submit herewith the duly filled-in /attestation form for verification of character and antecedents from the Police Authorities. I understand that my confirmation in the Bank’s service will be subject to satisfactory report regarding my character and antecedents from the Police Authorities. In case the Police enquiries are not completed before the confirmation becomes due, then I should be confirmed in the Bank’s service subject to satisfactory report from the Police Authorities. If the Police report later on turns out to be adverse my service should be terminated forthwith without assigning any further reason and without prejudice to such further actions as may be taken under the provisions of the Indian Panel Code.

Place:_______________

Date:_______________ (Signature of the Candidate) Name:_________________ Post:_________________ Roll No:_______________

SUTLEJ GRAMIN BANK H.O. A-4 CIVIL LINES, BATHINDAPHONE NO.0164-2212885 FAX.0164-2212132Ref: RRB/2015/ Date:

The District Magistrate

________________

Dear Sir,

REG: VERIFICATION OF CHARACTER AND ANTECEDENTS OF SH./SMT/KUM __________________________________________________________

We shall be glad if you will please arrange to furnish us the Character and antecedents in respect of:

Sh./Smt./Kum.________________________________________________________

Son/Daughter of Sh.________________________________________________

Resident of _________________________________________________________

Affix

Passport

Size

photograph

Required for our consideration in connection with his/her Regular appointment in Bank’s service.

You are requested to do the needful. An early action is solicited.

Yours faithfully,

Gen .Manager

CC: The Superintendent of Police,

Gen. Manager

MEDICAL REPORTTo be filled by Examinee himself

A)Name______________________________-__________________________(in block letters)Address:________________________________________________________________________________________________________________________________

1.Have you ever had any serious illness or Surgical operation?2.Have you or has any member of yourFamily ever been under treatment forTuberculosis?3.Have you or has any member of yourFamily ever suffered from mental disease,Fits or epilepsy or been treated in any Institution for any kind of these disease?4.Have you or has any member of yourFamily ever been under treatment for Trachoma?

State if ‘Normal’ – if not, give particulars of any departure from normal:_______________________________________Husband or Single Man Wife or Single woman

Date of Birth: ____________ Date of Birth:___________

B) To be filled in by the examining Doctor:

Max. Min. Max. Min.

a. Heart

b. Blood Pressure

c. Lungs

d. Nervous system

e. Mental condition & Intelligence

f. Digestive organs

g. Skeleton bones & joints

h. Skin

i. Hearing

j. Sight: a) Without glass

b) With Glass

R

R

L

L

R

R

L

L

k. Genito Urinary Organs

l. Is albumin or sugar present in urine

m.

Teeth

n. Deformities

o. Height

p. Weight

REMARKS: In case where the Medical Examiner is unable to describe the examinee as being in perfect health and development, he should state the exact nature of the defect which he finds and whether it is of permanent or temporary nature.

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

I certify that I have examined the above named and that the results are as set forth and I certify that in my opinion, subject to any special observations under

“Remarks” the above-named is in good health and of sound constitution and not suffering from any mental or bodily defect.

Signature

Name__________________

Qualification_____________________

Reg. No. __________________

Address: _____________________________________

Dated:

SUTLEJ GRAMIN BANK(SPONSORED BY PUNJAB & SIND BANK)

HEAD OFFICE, A-4, CIVIL LINES, BATHINDAPH.0164-2212885,2219805 FAX:0164-2212132REF: RRB/HO /2015 DATE:

ANNEXURE-II

ATTESTATION FORM

The furnishing of false information or suppression of any factual information in the attestation form would be a disqualification and is likely to render the candidate unfit for appointment in the Bank. If the fact that false information has been furnished or these has been suppression of nay factual information in the attestation form comes to notice any time during the service of a person, his services would be liable to be terminated.

SURNAME NAME

1. Name in full (in block capital):With aliases if any, (please Indicate if you have added or Dropped at any stage any part Of your name or surname.

2. Present address in full (i.e. Village, Thana & District, or House No., Lane/Street/Road And Town).

3. (a) Home address in full (i.e.Village, Thana and District, or House No., Lane/Street/Road,Town and name of the Distt. H.Q.)

(b) If originally a resident ofCountry other than India, the address in that country and the date of migration to Indian Union.

Passport

Size

photograph

4. Particulars of places (with period of residence) where you have reside for more than one year at a time during the preceding five years.

From To Residential address

In full (i.e. village,

Thana and Distt. Or

House no. Lane/street/

Road and Town)

Name of the Distt. Head

Quarters of the place mentioned in the preceding

column.

SURNAME NAME

5.1 (a) Father’s Name in full with Alias, if any(b) Present Postal address(c )Permanent Home address(d) Profession(e) If in service, give-designation and official address

5.2 (a) Husband’s Name in full(b) Profession(c ) Designation and office address

6. Nationality of(a)Father (a)

(b)Mother (b)(c ) Husband/Wife (c )

7. Exact date of birthPresent ageAge at Matriculation

8. (a) Place of Birth(b) Distt. And State in whichSituated(c ) Distt. And State to which You belong

9. (a) Your religion

(b) Are you a member of a Scheduled Caste/Scheduled Tribe?Answer “Yes” or “No”And if the answer is Yes,State the name thereof.

10. Educational Qualification showing place of education with years in Schools and Colleges since 15th year of age.

Name of School/

College with full

address

Date of entering

Date of leaving

Examination passed

Year of passing

11.If you have, at any time, been employed, give details:

Designation of post

Held or description of

work

Period

From To

Full Address of the office, firm or

institution

Reasons for leaving the job

12. Have you ever been arrested, or kept under detention or bound down/fined/convicted by a Court of Law for any offence, or debarred/disqualified by the Public Service Commission from appearing at its examination selections or debarred from taking any examination or restricted by authority/institution?If answer is “Yes” full particulars of the case detention, fine conviction, sentence etc. should be given.

DECLARATION

I Certify that the foregoing information is correct and compete to the best of my knowledge and belief, I am not aware of any circumstances which might impair my fitness for the employment in the Bank. I have/will have no objection to the Bank making enquiries at any time (immediately/in the application, in any manner the Bank decide to do so inclusive of Police enquiry into my antecedents.

SIGNATURE OF CANDIDATE

DATE:

(Undertaking to be submitted only by a candidate who belongs to Schedule Caste or Schedule Caste or Schedule Tribe Community)

The Chairman.Sutlej Gramin Bank,Head Office, A-4, Civil Lines,Bathinda With reference to my appointment in the service of Sutlej Gramin bank, I hereby undertake as under:“The appointment is provisional and is subject to the Caste/Tribe certificate being verified through the proper channels and if the verification reveals that the claim for belong to Schedule Caste or Schedule Tribe, as the case may be, is false, the services will be terminated forthwith without assigning any further reason and without prejudice to such further actions as may be taken under the provisions of the Indian Panel Code for production of false certificates. Further, I understand that my confirmation in the Bank’s service will be subject to satisfactory report regarding my community certificate being verified through the proper channels. In case the reports are not completed before the confirmation becomes due, then I should be confirmed in the Bank’s Service, subject to satisfactory report from the appropriate Authorities. If the report later on turns out to be adverse my service should be terminated forthwith without assigning any further reason and without prejudice to such further actions as may be taken under the provisions of Indian Panel Code.”

Yours faithfully,

-------------------------------

(Signature of the candidate)

Name: Post:

Roll No.DATE:PLACE:

(Declaration for seeking reservation as an Other Backward Class Candidate)

The Chairman.Sutlej Gramin Bank,Head Office, A-4, Civil Lines,Bathinda.

I _______________________son/daughter/wife of Sri ______________________ resident of H.No. /Lane/Street/Road/Village Post Office/Thana/Town/City/PIN Code ___________________________________________________________________ district______________________state __________________________ hereby declare that I belong to the ___________ community (_____________ Caste), which is recognized as a backward class by the Government of India for the purpose of reservation in services as per order contained in department of Personnel and Training Office Memorandum No.36012/22/93-Estt. (SCT) dated 08.09.1993 (Si.No. 198 of Swamy’s Annual 1993). It is also declared that I do not belong to person/sections (Creamy Layer) mentioned in Column 3 of the Scheduled to the above referred Office Memorandum dated 08.09.1993.

Yours faithfully,


Name Post:

Roll No.DATE:

PLACE:NB: OBC certificate should not be more than one year old as per advertisement.

I, ________________________ Son/daughter / wife of ______________________ by caste _____________________________________In consideration of the Sutlej Gramin Bank (hereinafter called the Bank) taking me into its employment on probation for ___________________________________________________________________Do hereby bind myself, my heirs, executors and administrators unto the Bank that I will, during all the time that I continue in the probationary employment of the Bank in any capacity, faithfully, diligently and carefully attend to the business of the Bank and to the best of my skill and ability perform all duties that may be required of me and observe and execute all instructions or regulations as have been or may be given to me from time to time by anyone in the employment of the Bank who may be set over me.That, I will keep secret all transactions that may come to my knowledge whilst in the employment of the Bank and will honestly and truly account to the Directors, Managers, Inspectors or others Officers of the Bank having authority in that behalf for all sums of money, bills, promissory notes or other securities, property or effects of every kind belonging to the Bank or any or its Officers or customers, with which I may be entrusted or which at any time or in any way during my probationary employment come to my hands or under my control and that I will, when required, pay and deliver the same to any person or persons to be appointed on behalf of the Bank to receive the same.That, I will on demand pay and make good to the Bank the amount of all loss, damage and expenses which may be sustained or incurred by the Bank by any defalcations and misfeasance’s on my part or through the non fulfillment of any of the obligations hereinbefore contained or by or through any act, neglect or default done, admitted or suffered, by me at any time while I continue in the probationary employment of the Bank and that a Certificate in writing only certified by the Bank stating the amount at any time payable by me hereunder.IN WITHNESS Where of I have set of my hand this _________day of_________2015.


Name: Post:

Roll No.

DATE:PLACE:

SCHEDULE – I

[See regulation 5(4)(ii)]

DECLARATION OF MARITAL STATUS

I,Shri/Smt/Kum ____________________ s/o w/o d/o_______________________

declare as under:

(i) That I am unmarried/a widower/widow.(ii) That I am married and have only one spouse living.(iii) That I have entered into or contracted a marriage with a person having a spouse living. I may be granted exemption on the basis of ground given below. Application for grant of exemption is enclosed.

Ground:

2. I solemnly affirm that the above declaration is true and I understand that in the event of the declaration being found to be incorrect after my appointment, I shall be liable to be dismissed from service.

Date: Signature

SCHEDULE - II(See regulation 19)

DECLARATION OF FIDELITY AND SECRECY

I, _____________________________, do hereby declare that I will faithfully, truly and to the best of my skill and ability execute and perform the duties required of me as officer or employee of the Sutlej Gramin Bank and which properly relate the office or position held by me in the said Bank.

I further declare that I will not divulge or allow to be divulged to any person not legally entitled thereto any information relating to the affairs of the said Bank or to the affairs of any person having any dealing with the said Bank and nor will I allow any such person to inspect or have access to any books or documents or electronic records belonging to or in possession of the said Bank and relating to the business of the said Bank or the business of any person having any dealing with the said Bank.

Signed before me

Signature:

Name in full:__________________________

Designation:_________________________

Signature:_______________________

Name in full:____________________________

Designation:__________________________

Place:________________________________

Date:____________________________

SCHEDULE – III

(See regulation 73)

DECLARATION OF DOMICILE

Place…………………………………………….. Date………………………………………………..

The undersigned having been appointed in the service of the Sutlej Gramin Bank hereby declare......................................................(Place) in...................................................................(District) as my place of domicile.

1The above is my place of birth.

or

* The above is not my place of birth. my place of birth is. ________________ (Place) in________________ (District) but ...........................................(Place) has been declared as my place of domicile for the reasons given below.

Signature

Name in full_________________________________

Designation and Nature of appointment ___________________________________________________

Date of appointment : _____________________________________

* Strike out whichever is not applicable.

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