APPLICATION FORM

To

The Deputy General ManagerRegional Office Vijaya BankNo.31-3-4B,Masjid StreetStreet,MaruthinagarVijayawada,ApPIN – 520004

With reference to your advertisement in ___ONLINE____ dated _03-07-2014_, I submit my application in the prescribed format.

Name of the post applied for : PEON

1. CATEGORY TO WHICH I BELONG: SC: ST: OBC: GEN: (Indicate by mark in appropriate box.)

2. FULL NAME IN BLOCK LETTERS: (Leave one space blank between two parts of your name)

Mr./Ms. P A T H A N S H A M S H E ER K H A N

3. (a) ADDRESS FOR CORRESPONDENCE:

1 7 - 9 - 1 2/A , M U B A R A K N AG A R , 2 1 W A R D , M O S Q U EB A C K S I D E , P O N N U R ,G U N T U R Pin Code: 5 2 2 1 2 4

3. (b) TELEPHONE NO. WITH STD CODE MOBILE NO. 7386155794

4. DATE OF BIRTH : DD M M YY

5. AGE (As on 30.09.2013) : _______23___ completed years.

6. PARTICULARS OF FEES (Demand Draft)

Name & Address of issuing Bank/Branch

Drawn in favour of Date of Issue

DD No. Amount

(Application fees should be sent in the form of DD favouring " Vijaya Bank - Recruitment of Peons- 2013-14 " and payable at VIJAYAWADA Cash, Money Order, Postal Stamps/postal orders will not be accepted.

PLEASE AFFIX YOUR RECENT PASSPORT SIZE PHOTOGRAPH

AND SIGN ACROSS

7. INDICATE BY MARK IN APPROPRIATE BOX:

i) GENDER: MALE FEMALE

YES NOii) Are you a widow?

YES NOiii) a) Are you an Ex-serviceman:

b) In case of Ex-serviceman/Commissioned Officer/Police Officer/ Other Equivalents, specify 1. Date of discharge: __________________ 2. Rank at present/last held A) Acting________ w.e.f._______ B) Substantive______ w.e.f.______

OC HI VIiv) SUB-CATEGORY UNDER

PERSONS WITH DISABILITY (Indicate by mark in appropriate box.)

v) Are you a candidate who is ordinarily being domiciled in Kashmir Division during the period 01.01.1980 to 31.12.1989. YES NO

vi) Whether children/family members of those died in 1984 riots :

YES NO

vi) Whether you belong to Minority community : YES NO If yes, please state the religion: __MUSLIM__________

vii) In case of SC/ST/OBC Candidatea) Name of the Caste/Tribe/Class : _____________b) Name of the state to which I belong : _____________

viii) Married/Unmarried :

8. EMPLOYMENT EXCHANGE REGISTRATION NUMBER & NAME OF THE EMPLOYMENT EXCHANGE:__________________________if any.

9. FATHER’S/HUSBAND’S NAME (indicate appropriately):

Mr. PATHAN A G J A R A L I KHAN

10. NATIONALITY : ____INDIAN______

11. PLACE OF BIRTH: Place _CHERUKUPALLI Dist._GUNTUR_____ State__ANDHRAPRADESH_____

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12. PERMANENT ADDRESS:17 - 9 - 12/A M U B A R A K N A G AR 2 1 W A R D M O S Q U E S ID E P O N N U RG U N T U R Pin Code: 5 2 2 1 2 4

13. EDUCATIONAL QUALIFICATION (From VIII Standard onwards; as on 30.09.2013):

Examination Passed

Name of the Institution studied

Month & Year of passing

%age of marks

SSC MUNICIPAL HIGH SCHOOL

MARCH-2006 79.5

INTER MEDIATE EDUCATION

KSJ COLLEGE MARCH-2008 65.7

(If space is not sufficient, please attach separate sheet)

14. PARTICULARS OF EXPERIENCE, IF ANY:

Name of the employer & nature of activities carried by

them

Period of Service

From To

Length of Service

Nature of duties

performed

Remarks (Reason

for leaving service)

Years Month

(If space is not sufficient, please attach separate sheet. Copies of appropriate certificate to be attached).

15. Languages known : (Indicate by mark in appropriate box)

(A) ___ENGLISH______ Read/Write/Speak

(B) _______HINDHI ___ Read/Write/Speak

(C) ___TELUGU ______ Read/Write/Speak

(D) __________________ Read/Write/Speak

16. Details of disciplinary proceedings and : punishment, if any, imposed in the course of employment by the employer

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17. Any other information : ________________________________

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 is liable to be cancelled/terminated. I agree that Bank has right to transfer me to any part of the State 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 said advertisement can be instituted by me only in VIJAYAWADA. I undertake to abide by all the terms and conditions mentioned in the advertisement given by the Bank.

PLACE: ______________ DATE : _____________ SIGNATURE OF THE APPLICANT

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