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, To, Paste your recent
passport size
Baroda Rajasthan Gramin Bank Baroda Rajasthan Gramin Bank, photograph and sign
Recruitment Project-2009, Recruitment Project-2009, it across. Please
retain with you three
Post Box No.7731, Post Box No.8591, copies of the same
photo for subsequent
Borivali (West), Kandivali (East), use
MUMBAI - 400 092 MUMBAI - 400 101

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 Bhilwara Churu Sawaimadhopur

8. Gender (Please indicate by putting √ in the appropriate BOX)

Male Female

9. 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. Religion _________________ Sub-caste __________________
b. Name of the State/UT to which you belong : ________________
c. If Person With Disability
(Please indicate by putting √ in the appropriate BOX)

Orthopaedically Handicapped Hearing Impaired Visually Handicapped

(OH) (HI) (VH)

Percentage of Disability : ________________________

(Please attach attested photostat copy of medical certificate issued by Competent
Authority)
d. Are you eligible and intend to use the Service of Scribe?
(Please indicate by putting √ in the appropriate BOX)

Yes No

e. 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 : _________________ w.e.f. _____________
b) Substantive : _________________ 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 Date of Issue Demand Draft / Amount
Issuing Bank / Drawee Bank / Branch Bankers in Rs.
Branch 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 Name of the Board Subjects studied Month & % of Class /
Passed / University Year of Marks Division
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

 (4)
20. Particulars of Post Qualification Experience including the Present Occupation / Job.

Name of the Designation Period of service Length of Nature of Remarks

employer(s) firm and rank if service duties (Reasons
etc. and the any Years, performed for leaving
nature and details Months, in detail service)
of activities Days
carried out by the
employer From 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) The post name and post code you have applied for.
b) Category/Sub-category and have enclosed copies of necessary certificates for
SC/ST/OBC/PWD/EXS candidates.
c) Details regarding fees (Bank demand draft / Bankers Cheque)
d) Address for communication.
e) Separate application form with requisite fees for each post is sent.
f) Details for claiming relaxation in age and the relevant certificate is enclosed.
g) Two self-addressed unstamped envelopes of 11 x 5 size.
h) An attested copy of Domicile Certificate is enclosed.
i) 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