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Recruitment of Office Assistants (Multipurpose), Officer JMG-I, Officer MMG-II and Officer MMG-III

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Please paste your recent passport size photograph and sign across it. Please retain atleast 5 copies of same photograph with you for subsequent use.

Registration #: Full Name : Post : Post Code : Category : If Person with Disability : Type of Disability : Percentage of Disability : Do you intend to use the services of a scribe (only for VI & OC candidates whose writing speed is affected by cerebral palsy) : Are you candidate who had ordinarily been domiciled in Kashmir Division of the State of J&K during the period 1-1-1980 to 31-12-1989 : Whether you belong to Religious Minority Community : Religion to which you belong : Are you an Ex-Serviceman and Commissioned Officers including ECOs/SSCOs? : Are you a disabled Ex-Serviceman (DISXS) ? : Actual Period of service rendered in defence services as an Ex Serviceman (in months) : Are you Dependent Ex-Serviceman (DXS) ? : Are you Employees who have completed 5 years of service in RRBs? :

11432 Vikas Verma Office Assistants (Multipurpose) 07 OBC NO NA NO NO -NO NO -NO NO

Are you seeking relaxation under widow / divorced women / women judicially Separated from their husbands NO and who are not re-married? : Domicile of chhattisgarh : Nationality : Centre of Examination : Centre code : Application Fee / Postal Charges Details : Payment In : Transaction ID : Branch Name : Branch Code : Date of Issue : Amount : Chhattisgarh Gramin Bank 0000103750 Pandri Tarai Raipur 00128 18-11-2011 300 YES INDIAN RAIPUR 11

Personal Details : Date of Birth : Age completed as on 30-09-2011 : Gender : Husband's Name/Father's Name : Mother's name : Contact Details: Address for Correspondence : Z-14 Dubey Colony Behind Sai Mandir DalDal Seoni Mowa Raipur 25-06-1988 23 MALE Ramesh Kumar Verma Aruna Verma

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District : State : Pin code : Permanent Address : Raipur CHHATTISGARH 492001 Z-14 Dubey Colony Behind Sai Mandir DalDal Seoni Mowa Raipur District : State : Pin code : Phone Number : Mobile Number : Email ID : Qualification Details (as on 30.09.2011): Exam Passed Graduation / Diploma : Diploma in Banking : Working Knowledge of Computers : Details of Computer Knowledge : Post Qualification work experience details as on 30.09.2011 (Start from present Employer) : Name of the Employer CHiPS Designation Project Trainee From(mm/yyyy) 07/2011 To(mm/yyyy) 09/2011 Length of Service (YY/MM) 0/2 Nature of duties performed Miantenance manage ment of projects 4 Reason for Leaving NA Name of the Course / Degree Information Technology NO YES MS Office Networking Year of Passing 2011 % of Marks 74.68 Raipur CHHATTISGARH 492001 9770187550 vicas.r.verma@gmail.com

Total Relevant Experience (in months) : Other Details : Would You like to undergo Pre-Exam Training (SC/ST/Minority Community/EXS): If Yes ,Centre for Training : --Languages Known Hindi English CHHATTISGARHI Read YES YES YES Write YES YES YES

Speak YES YES YES

DECLARATION:
I hereby certify that the above information furnished is correct to the best of my knowledge and belief. I have not suppressed any material fact or factual information in the above statement. I am aware that in case I have given wrong information or suppressed any material fact or factual information or I do not satisfy the eligibility criteria according to the advertisement, then my candidature will be rejected/ service terminated even after permanent employment without giving any notice or reasons thereof. I hereby certify that I am satisfying the eligibility criteria for the post applied for in terms of advised criteria in respect of age, caste, educational qualification etc. I hereby agree that any legal proceeding in respect of any matter or claims or disputes arising out of application or out of said advertisement can be instituted by me only at Raipur and courts/ Tribunal/ forums at Raipur only, shall have sole and exclusive jurisdiction to any cause/ dispute. I undertake to abide by all the terms and conditions in the advertisement given by the Bank.

Place: Date: 23-11-2011 Signature of Applicant

Vikas Verma

Please retain your Registration No. and Password emailed to you carefully for further reference NOTE: Please DO NOT SEND application print-out to the Bank