Application Form for Csp

Application Form for Csp

Annexure “A”

APPLICATION FORM FOR CSP

# / Particulars / Details
1. / Location (Village / Town) /
  1. Gram Panchayat Name/ Ward No.
  2. Block / Tehsil
  3. District
  4. State
  5. Pin Code

2. / Name (IN BLOCK LETTERS)
3. / Photo /
4. / Father’s / Husband Name
5. / Date of birth (dd/mm/yyyy) & Age
6. / Gender (Please tick) / Male Female Others
7. / Marital Status (Please tick) / Married Unmarried
8. / Education (Please tick) / Below Class X Class X Class XII
Graduate Postgraduate & above
9. / Permanent Address /
  1. P.O.
  2. Tehsil
  3. District
  4. State
  5. Pin

10. / Communication Address /
  1. P.O.
  2. Tehsil
  3. District
  4. State
  5. Pin

11. / Telephone No. (With STD) / Residence -
Office -
Mobile No. -
12. / Email id
13. / Currently Banking with (Bank)
14. / Bank A/c no.
15. / Cheque facility (Please tick) / Available Not Available
16. / Proof of Name (Please tick) / Driving License PAN Card
Voter’s ID Card Passport
17. / Proof of Address / Electricity Bill NSC
Telephone Bill LIC Policy
GAS Connection Letter from landlord
18. / PAN No.
19. / Aadhaar No.
20. / CIBIL Score
21. / Present Business / Occupation
22. / Computer Literacy / Yes No
23. / If yes, nature of qualification
24. / If you already own a business or are working, your revenue / income per month is
(please enclose copy of IT return / pension payment certificate) /
  1. Less than Rs. 5,000
  2. Rs. 5,000 to Rs. 10,000
  3. Rs. 10,000 to Rs. 20,000
  4. Rs. 20,000 to Rs. 30,000
  5. More than Rs. 30,000

25. / Do you have any experience in selling financial products? Is yes, give details.
26. / Languages known (say fluent / not so fluent) / Read / Write / Speak
English
Hindi
Regional Language (specify)
Any other (specify)
27. / No. of years of stay in the town / village
28. / Do you have any police records? If yes, give details
29. / Names, address and occupation of two people to whom reference can be made / 1)
2)
30. / Political Affiliation, if any
31. / Defaults if any to Banks / Financial Institutions
32. / Infrasturcture available; (office, area, location, computer, internet, Tel no, etc.)
33. / Name of the office from which retired
34. / Position at the time of retirement (Please give brief of various position held and role)
35. / Any disciplinary action taken against you while in service (If yes, please give details. Please enclose a certificate of Conduct from your last employer)
36. / Particulars of liabilities
37. / Particulars of movable property and Investments.
38. / Particulars of Immovable property / A) Land: Village Survey / Patta No. Area
B) House / Flat Location Built up area Year of construction (Property details to be enclosed)
39. / Are you willing to invest in the POS machine and other equipments required for carrying out transactions as Business Correspondents?
40. / What is the cash balance you are ready to invest for making cash payments / receipt of deposits as Business Correspondents?

I certify that the above information is true to the best of my knowledge and belief.

Date:

Place:Signature of the applicant

(Enclose copy of ID & address proof, CIBIL, PAN)

Reference 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 Mr. / Ms. / Mrs. ……………………………………………………has been a resident of…………………………… village /town of ……………………….district in ………………………………….State of Rajasthan for the 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 Mr. / Ms. / Mrs. ……………………………………………………has been a resident of…………………………… village /town of ……………………….district in ………………………………….State of Rajasthan for the period of …………..years and has been known to me for period of …………..years.

(Signature)

Name of Referee…………………………………………………………….

Address……………………………………………………………………….

…………………………………………………………………………………

Designation…………………………………Title…………………………...

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