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ON-LINE APPLICATION FOR RECRUITMENT FOR THE POST OF OFFICE ASSISTANT (MULTIPURPOSE)-GROUP-B

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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 : Category : If Physically Challenged : Type of Disability : Percentage of Disability : Do you intend to use the services of a scribe(only for VI/OC candidates whose writing speed has been affected by cerebral palsy) : Whether you belong to Religious Minority Community ? : Religion to which you belong : Are you an Ex-Serviceman ? : Are you a disabled Ex-Serviceman (DISXS) ? : Period of service rendered in defence services as an Ex-serviceman (in months) : Are you Dependent Ex-Serviceman (DXS) ? : Are you seeking Relaxation under Widows/Divorced women & women judicially separated from their husbands & who are not remarried ? : Are you domiciled in Kashmir Division of Jammu & Kashmir State during the period from 01.01.1980 to 31.12.1989 Domicile of Bihar: Nationality : Centre of Examination : Centre code : Application Fee / Postal Charges Details : Payment In: Transaction ID : Branch Name : Branch Code No : Date of Deposit : Amount :

32744 CHANDAN KUMAR SC NO NA NO -NO NO

NO NO NO YES Indian Patna 11

UCO BANK AA44886 JAWAHARLAL ROAD MUZAFFARPUR 0119 25-11-2011 50

Personal Details : Date of Birth : Age completed (as on 01.10.2011) : Gender : Marital Status : Father's Name/Husband's Name : Mother's name : Address for Correspondence : 20-06-1991 20 MALE UnMarried DUKHAN RAJAK VEENA DEVI VILL-DADAR POST-KOLHUA PAIGAMBARPUR P.S-AHIYAPUR District : State : Pin : Permanent Address : MUZAFFARPUR BIHAR 843108 VILL-DADAR

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POST-KOLHUA PAIGAMBARPUR P.S-AHIYAPUR District : State : Pin : Contact Details: Phone No : Mobile No : Email ID : Qualification Details (As on 01.10.2011): Exam Passed Graduation : Working Knowledge of Computers : Details of Computer Knowledge: Post Qualification work experience details (Start from present Employer): Name of the Employer & Nature of Employment Designation and Rank From(mm/yyyy) To(mm/yyyy) Nature of Duties Performed Reason for Leaving Years of Service (YY/MM) Total Experience (in months) : Other Details : Whether desirous of taking Pre-Exam Training (Only for SC/ST/Minority Community/Ex-servicemen) : If Yes ,Centre for Training : NO -Languages Known Hindi English Read YES YES Write YES YES Speak YES YES Name of the Subject/Stream COMMERCE Year of Passing 07-06-2011 YES DCA % of Marks 58.00 Class / Grade Second Class 9576237814 ersrikantsaurav@gmail.com MUZAFFARPUR BIHAR 843108

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 MUNGER and courts/ Tribunal/ forums at MUNGER 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: 29-11-2011 Signature of Applicant

CHANDAN KUMAR

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