BARODA RAJASTHAN KSHETRIYA GRAMIN BANK

(HEAD OFFICE : AJMER)

CHECK LIST FOR PERSONAL FILE

Name _________________________________________ ROLL NO. : _____________________

Caste/Category :______________ (SC/ST/OBC/PC/EXS/Others)

PWD ______% OF DISABILITY_______

Form No. MARK ( √ ) or

For Regional /Head Office Use Only Comments of Verifying
Officer
1 Appointment Letter and Acceptance Letter
2 Joining Report
3 Service Entry Record
4 Indemnity Bond with Surety
5 Police Verification Report
6 Medical Certificate
7 Assets And Liability Form (Bank)
8 List of dependents for Health Insurance Scheme
9 Gratuity Nomination Form
10 UCMR Form
11 ID Card Form
12 Specimen Signature Form
13 Relieving Order From Previous Employer

Signature Of Verifying Officer

NAME _____________________
Place: E.C. NO. _____________________
Date : DESIGNATION _____________________
 Joining Report

[to be submitted at the time of joining]

The General Manager/ Regional Manager,

Baroda Rajasthan Kshetriya Gramin Bank,
Head Office/ Regional Office,
…………………..

Respected Sir,

Ref: Offer letter for appointment bearing No. HO/2018-19/HRM/ ……….

dated ………………..

Reg: Offer of appointment in Baroda Rajasthan Kshetriya Gramin Bank

on the post of Office Assistant (M)/ Officer Junior Management
Scale-I / Officer Middle Management Scale-II

I acknowledge the above offer letter offering me appointment as

……………………….…….. in your Bank.

I, hereby, accept all the terms and conditions laid down in the appointment
letter, which I have thoroughly read and understood. I also agree to abide by
the Baroda Rajasthan Kshetriya Gramin Bank (Officers and Employees)
Service Regulation, 2010 and amendments made therein for the staff from
time to time.

In compliance to above offer letter No. HO/2018-19/HRM/……….. dated

……………….., after completing all formalities (enclosed) I, hereby,
submit my joining report for the post of …………………………………..
today i.e. (dd/mm/yyyy) ………………… (forenoon/afternoon).

Kindly allow me to join the Bank.

Thanking you,

Yours faithfully,

_________________
( )

Date:--------------------------- Address: ----------------------

-----------------------------------
Place : ------------------------ -----------------------------------
-----------------------------------
Mob.
 BARODA RAJASTHAN KSHETRIYA GRAMIN BANK
(HEAD OFFICE : AJMER)
lsok izo”s k vfHkys[k
SERVICE ENTRY RECORD
d-dw-la- EC NO. ____________
1. iwjk uke ¼cM+s v{kjks es½a
Full Name (Block Letters) :_______________________________

2. firk dk uke
Father’s Name :_______________________________

3. tUe frfFk
Birth Date :_______________________________

4. lkekU; vtk vttk vfio Hkw lSfud

(a) Gen SC ST OBC XSM
(b) PC OH HL VI %age

5. Religion / /keZ :_______________________________

6. ¼v½ “kS{kf.kd ;ksX;rk

(a) Academic Qualification + :_______________________________

¼c½ info ikB;Øe esa fo”ks’k fo’k;

(b) Subject of specialization :_______________________________
in Degree Course

7. iwoZ vuqHko ¼;fn gks½

Previous experience (if any) :_______________________________

8. Hkk’kkvksa dk Kku
Languages known

Hkk’kk Language cksyuk Speak i<+uk Read fy[kuk Write

MARK ( √ ) MARK ( √ ) MARK ( √ )
1.
2.
3.

9. dk;Zxzg.k dh rkjh[k
Date of Joining Service :_______________________________

10. jkstxkj dk Lo:i ifjoh{kk

Nature of employment : Probation
11. inuke Designation :_______________________________

12. vkjfEHkd osru Starting Salary :_______________________________

13. igpku fpUg Identification marks :_______________________________

14. ifjp;nkrk 1-____________________________

Introduced by (Names of Referee) 2.____________________________

15. D;k vki cSad ds fdlh funs”kd vFkok vU;

deZpkjh ds laca/kh gS? ;fn gks rks mudk iwjk
uke rFkk laca/k dk mYys[k djsAa
Are you a relative of any Director
or the employee of the Bank ? If so,
please state the full name of such a
relative and the nature of relation.
:_______________________________
_______________________________
_______________________________
_______________________________

+ d`i;k fo”ofo|ky; vFkok fudk; dk uke nsAa

+ Please state the name of the University or other body.

16. irk Address orZeku Present :_______________________________

_______________________________
_______________________________
_______________________________

LFkk;h Permanent :_______________________________

_______________________________
_______________________________
_______________________________

17. eksckbZy ua- Mobile No. :______________________________

18- bZ&esy E-Mail address :______________________________

19- vf/kokl LFkku Place of Domicile :_______________________________

20. gLrk{kj Signature :_______________________________

rkjh[k fooj.k lR;kfir

Date : ___________ Particulars verified
vf/kdkjh @Officer
d-dw-la- E.C.no.
 (To be submitted at the time of joining By Officer Middle Management Scale-II )
INDEMNITY BOND WITH SURETY
(To be stamped of as per State Stamp Rules and Notarized)
This Indemnity is made and executed at ___________________ day of __________2019 by
Sh./Smt./Miss____________________________________________________________
Son/Daughter of Shri ___________________________________________________ a
permanent resident of _______________________________________________________
___________________________________________________________ hereinafter called
“Selected candidate”, the party of the First Part which expression shall unless repugnant to
the subject or context mean and include legal heirs, representatives and assigns, has been
offered an appointment for the post of Officer Middle Management Scale-II vide letter No.
HO/2018-19/ HRM/.............. dated . . . . . . . . . . . by the Employer Bank, i.e. Baroda
Rajasthan Kshetriya Gramin Bank. AND
Shri ______________________________________S/o Shri ______________________ a
permanent resident of _______________________________________________________
________________________________________________________________ hereinafter
called “Surety”, the party of the Second Part which expression shall unless repugnant to the
subject or context mean and include legal heirs, representatives and assigns, have at the
request of the First Part stand as Surety to the Financial Bond extended by First Part (Selected
candidate) in favour of Baroda Rajasthan Kshetriya Gramin Bank, a body corporate
constituted under the Regional Rural Banks Act, 1976 (21 of 1976) Regional Rural Banks
amendment Act,2015 and Gazette Notification dated 01.01.2013 issued by the Government
of India, Ministry of Finance, Department of Economic Affairs (Banking Division) having its
Head Office at Ajmer hereinafter called “Employer Bank” which expression shall unless
repugnant to the subject or context shall mean and include their successors, executors and
administrators.
Contd……..2
 (2)
WHEREAS the Candidate has been selected for appointment as Officer Middle
Management Scale-II in the service of the Employer Bank.

WHEREAS an Offer of Appointment containing the terms and conditions of the appointment
as Officer Middle Management Scale-II has already been issued to the Selected candidate
vide letter No. HO/2018-19/HRM/………......... dated . . . . . . . . .. of the Employer Bank.

WHEREAS the acceptance of the terms and conditions of the appointment has already been
communicated to the Employer Bank on dated ________________ by the Selected candidate.

WHEREAS one of the terms and conditions of the appointment is that the Selected
candidate has to serve the Employer Bank i.e. Baroda Rajasthan Kshetriya Gramin
Bank for a minimum period of two years active service from the date of joining the bank
service, has to execute an indemnity with surety in favour of Employer Bank.

NOW THIS INDENTURE WITNESSETH as under:

1. In compliance of the aforesaid condition in the Offer of Appointment subject to
which the Employer Bank has agreed to give appointment to the selected
candidate, the selected candidate hereby undertakes to serve the Employer Bank
for a minimum period of two years active service.
2. The Selected Candidate agrees and undertakes, to indemnify the Employer Bank
that in case he/she commits breach of the above condition and resigns from or
leaves/abandons the service and/or neglects in performance of the duty assigned
to him leading to termination of his/her service as per Rules and Regulations by
the Employer Bank for all losses, costs, charges and expenses upto extent of Rs.
_____________ and pay an amount of Rs. __________ (Rs.
____________________________) only with the interest thereon @ 12 per cent
per annum from the date of breach of the above till payment as liquidated
damages/cost of training including on the job training, the expenses which the Bank
has incurred/may have to incur in recruiting another Selected Candidate at his/her
place, and also on account of business loss suffered/to be suffered by Employer
Bank during intervening period.
3. The party of the second part i.e. Sh.____________________________ S/o
Sh.___________________ agrees to stand as Surety for the due performance of
the obligation of the Selected Candidate under this agreement of indemnity.
4. The party of the Second Part undertakes and declares that he/she is having
satisfactory and adequate means, and stands as Surety for the due performance
of the obligation by the Selected Candidate under his bond. In case of breach of
the terms of this indemnity by the Selected Candidate and failure to indemnify the
Bank, to pay the amount of Rs. 2,00,000/-+ GST as per rate applicable (Rs. Two
lac + GST as per rate applicable only) together with interest thereon @ 12% per
annum from the date of breach to Employer Bank immediately on demand. The
Surety shall be jointly and severally liable to pay the aforesaid amount to the
Employer Bank.
Contd……..3
 (3)

5. Notwithstanding anything contained herein above, furnishing of this indemnity will

not create any right in favour of the Selected Candidate to continue in the service
of Employer Bank for the aforesaid term of two years active service, and the
Employer Bank shall always have the right to take appropriate action against
the Selected candidate as per terms of the appointment letter and/or the Rules and
Regulations of the Employer Bank as applicable, in case of commission of any
the Selected Candidate.
6. The amount specified above shall constitute a debt owing to the Employer Bank
and shall be recoverable from the Employee and the Surety jointly and severally
with interest thereon at the rate specified above till payment.
7. Apart from this indemnity, if the Selected candidate desire to leave the services of
the Bank, he will have to give one month notice under probation and after
confirmation three months notice to the Bank, failing which, Selected candidate
shall be liable to pay to the Employer Bank as compensation a sum equal to his
pay for the period of notice required.
Signed and delivered by the Party of the First Part i.e. the Employee having perused and
understood the contents terms of this Agreement .
Signed and delivered by the Party of the Second Part i.e. the Surety having perused and
understood the contents/terms of the Agreement.
IN WITNESS whereof, the Selected Candidate and the Surety have put their signatures
in the presence of the witnesses.

Photo of Signature of Candidate

Candidate Name :_____________________
& Signature
across

Photo of Signature of Surety

Surety Name :_____________________
& Signature
across

WITNESS:
1. Signature ___________________
Name : ____________________
Son/Daughter of : _______________
Full Address ___________________
______________________________
WITNESS:
2. Signature ___________________
Name : ____________________
Son/Daughter of : _______________
Full Address ___________________
______________________________
 CHARACTER AND ANTECEDENTS VERIFICATION REPORT (APPLICATION FORM)

To
The Superintendent of Police,
District Police Office,__________
Subject : Application for Employee Verification
Sir,
It is requested that I have been selected as............................................in Baroda Rajasthan Kshetriya
Gramin Bank, a Bank constituted under the RRB Act, 1976 and having its Head Office at Plot No. 2343,
IInd Floor, Vaishali Nagar, Ajmer-305 004. The Bank requires that my character and antecedents may
be verified and a Police Verification Report may be issued to me. My personal particulars are as follow:-
1. Full Name (Expanded Initials) : .........................................................
Alias (if any) : .........................................................
2. Father (Full Name) : .........................................................
3. Spouse (Full Name), if married : .........................................................
4. Occupation: .........................................................
5. Nationality : ........................Age..............Sex..............Caste..............
6. Mobile No............................
7. Permanent Address:-
H.No. ............................Sector/Village/Locality............................
Police Station............................District........................................ Photo
State..........................................Pincode...................................... (Self signed)
8. Proof of Identity (Voter Card/Driving Licence/Ration Card etc.)
9. Local (Current Address) : .........................................................
.........................................................
.........................................................
Residing at current address since : ..........................................
10. Particulars of Previous Employment, If any
Nature of Employment .........................................................
Address : .............................................................................
..............................................................................
..............................................................................
Particulars of Previous Employer..........................................
11. Particulars of relatives residing locally (Current) Local Address
S.No. Name Father's Name Occupation Local Address
(1) ....................... .......................... ........................ .......................
(2) ....................... .......................... ........................ .......................
(3) ....................... .......................... ........................ .......................

(Signature of Applicant)
(For use of S.P. Office)
Name of the Applicant : ........................................................
Father/Husband's Name : ..................................................... Photo
Address : .............................................................................. (Attested by
............................................................................. issuing
..............................................................................
Authority)

Report : .................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................
...............................................................................................................................................

(Signature of the issuing Authority)

Official Seal
 cSad fjdkWMZ ds fy,
cM+kSnk jktLFkku {ks=h; xzkeh.k cSad
¼iz/kku dk;kZy; % vtesj½
'kk[kk@dk;kZy; &&&&&&&&&&&&&&&

ifjlEifÙk;ksa rFkk ns;rkvksa dk fooj.k

Return of Assets & Liabilities

cM+kSnk jktLFkku {ks=h; xzkeh.k cSad ¼vf/kdkjh vkSj deZpkjh½ lsok fofu;e ds varxZr fnukad 31 ekpZ] --------------------------* dh fLFkfr

1- vf/kdkjh dk uke ¼dqy uke izFke½ &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ¼deZpkjh dwV la-½ &&&&&&&
2- inuke % &&&&&&&&&&&&&&&inLFkkiu dh 'kk[kk@dk;kZy; &&&&&&&&&&&&
3- orZeku ewy osru ¼:-½ &&&&&&&&& Js.kh@osrueku &&&&&&&&&&&& 4- lsok dh dqy vof/k &&&&&&&&&&&&&
i) vf/kdkjh ds :i esa &&&&&&&&&
ii) ;fn inksUur gq, gks]a ¼fyfid ds :i es½a &&&&&&&&&

* vf/kdkjh izfro"kZ] ml foRrh; o"kZ ds 30 vizSy ls igys ;g fooj.kh izLrqr djsAa fu;qDr@inksUur *vf/kdkjh* dks viuh fu;qfDr@inks Uufr dh rkjh[k rd
fooj.kh izLrqr djuh gSA
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
?kks"k.kk
eSa ,rn~}kjk ?kksf"kr djrk gw]a fd cM+kSnk jktLFkku {ks=h; xzkeh.k cSad ¼vf/kdkjh ,oa deZpkjh½ lsok fofu;e] 2010 ds izko/kkuksa ds v/khu esjs }kjk izLrqr dh tkus
okyh tkudkjh ds lac/a k esa layXu foojf.k;ksa vFkkZr vuqca/k ,] ch] lh] Mh esa nh xbZ fnukad 31 ekpZ] ---------------------- dh fLFkfr laca/kh tkudkjh] esjs Kku vkSj fo'okl
ds vuqlkj iw.kZ ,oa lR; gSA

rkjh[k %
LFkku % ¼vf/kdkjh ds gLrk{kj½

vf/kdkjh dk uke ¼dqy uke izFke½ &&&&&&&&&&&&&&&&&&&&
Js.kh@osrueku &&&&&&&&&&&&&&&&&&&&&
ml jkT;] ftyk]
miizHkkx] rkyqdk
Ø-
rFkk xkao dk uke]
la-
tgak lEifÙk fLFkr
gS
cSad fjdkWMZ ds fy,
cM+kSnk jktLFkku {ks=h; xzkeh.k cSad vuqcU/k * , *
¼iz/kku dk;kZy; % vtesj½
'kk[kk@dk;kZy; &&&&&&&&&&&&&&&
vpy lEifÙk dk fooj.k % fnukad 31 ekpZ] ------------
¼deZ-dwV la-½ &&&&&&&& inuke &&&&&&&&&&&&
ftyk@{ks= &&&&&&&&&
dSls izkIr fd;k \ ¼[kjhnk] ca/kd iV~Vk]
vpy lEifÙk dk iw.kZ ;fn vf/kdkjh ds Lo;a iSr`d HksVa ;k vU; rjhds ls½ izkfIr dh ykxr@
C;kSjk@o.kZu @fooj.k@ ds uke ls ugha gS] rks izkIr djus dh rkjh[k vkSj mu O;fDr;ksa
lEifÙk ls
ml O;fDr ls deZpkjh lEifÙk dk ewY; izkIr okf"kZd
uEcj ds uke] irk laca/k (Name, Address & Cost of fVIi.kh
(Details/ Description of dk laca/k crk,a vk;] ;fn
connection) ftuls lEifÙk izkIr dh gS acquisition/ value
Property/ distinctive ftlds uke ls lEifÙk dksbZ gks rks
vkSj bls izkIr djus gsrq fn;s x;s /ku of property
numbers) gS
dk L=ksr

rkjh[k % ----------------------------
LFkku % ---------------------------- ¼vf/kdkjh ds gLrk{kj½
uksV %&
1- ;fn lEifÙk ij iw.kZ LokfeRo (Wholly owner) ugha gS] rks ftruk fgLlk gS (Extent of share) dk mYys[k djsaA
2- dkWye ua- 6 esa fuEu dks n”kk;sa %&
(i) ;fn lEifÙk Ø;@cU/kd@iV~Vk }kjk vftZr dh gS] rks bls vftZr djus gsrq Hkqxrku dh xbZ jkf”kA (ii) ;fn yht ¼iV~Vk½ }kjk vftZr dh gS] rks bldk dqy okf’kZd fdjk;k
(Total annual rent)A (iii) ;fn lEifÙk mÙkjkf/kdj (Inheritance), migkj (Gift) ;k vnyk&cnyh (Exchange) ls vftZr dh gks] rks mls vftZr djus dh vuqekfur ykxr
(Approximate value of property so acquired) A
 cSad fjdkWMZ ds fy,
cM+kSnk jktLFkku {ks=h; xzkeh.k cSad vuqcU/k * ch *
¼iz/kku dk;kZy; % vtesj½
'kk[kk@dk;kZy; &&&&&&&&&&&&&&&
py lEifÙk dk fooj.k] fnukad 31 ekpZ]--------------------
vf/kdkjh dk uke ¼dqy uke izFke½ &&&&&&&&&&&&&&&&& ¼deZ-dwV la-½ &&&&&&&&& inuke &&&&&&&&&&&&&&&&&
Js.kh@osrueku &&&&&&&&&&&&&&&&&&&&& ftyk@{ks= &&&&&&&&&&&&&&&
[kkrk la-@ikfylh dc vkSj dSls
Ø- blls izkIr vk;
fooj.k laLFkk dk uke ua-@ “ks;j ua- @ jkf'k izkIr dh x;h
(Income
la- fMcsUpj ua-@ la[;k (Amount) (How & when
derived)
acquired)
1 udn tek jkf'k dk fooj.k
cSad esa tek,sa] thou chek ikWfylh] Mkd?kj esa tek] ih-
ih-,Q-] fdlh daiuh] udn tek ;k dksbZ vU; tek
jkf'k dk fooj.k

2 'ks;j] izfrHkwfr;ak] fMcsUpj rFkk vU; fuos'k] rFkk fn;s x;s _.k]
vkfn %
'ks;j] fMcsUpj rFkk fuos'k] fn;s x;s _.k] vkfn dk fooj.k
ftlesa jkf'k] daiuh ;k O;fDr dk uke Hkh fn;k tk,A
3 vU; py lEifÙk;kWa] mu lHkh oLrqvksa lfgr]
ftlesa izR;sd dk ewY; `25000@& ls vf/kd gksA
¼v½ oLrqvksa dk fooj.k ;Fkk&jsfÝtjsVj] Vh-oh-]
ysiVkWi] dEiwVj] ,-lh-] QuhZpj vkfn
lksuk] pkanh] xgus] ghjs tokgjkr vkfn
okgu (Vehicle)
¼c½ `25000@& ls de ewY; dh izR;sd oLrq dk
,deq'r ewY; (Lump-sum Value)
uksV% izfrfnu dke esa vkus okyh oLrq,a ;Fkk diM+]s crZu] fdrkcs]a phuh ds crZu] vkfn dk mYys[k djuk vko';d ugha gSA
rkjh[k % ----------------------------
LFkku % ---------------------------- ¼vf/kdkjh ds gLrk{kj½
 cSad fjdkWMZ ds fy,
cM+kSnk jktLFkku {ks=h; xzkeh.k cSad vuqcU/k * lh *
¼iz/kku dk;kZy; % vtesj½

_.k rFkk vU; ns;rkvksa dk fooj.k] fnukad % 31 ekpZ]------------------

vf/kdkjh dk uke ¼dqy uke izFke½ &&&&&&&&&&&& ¼deZ -dwV la-½ &&&&&&&&& inuke &&&&&&&&&&&&&&&&&&
Js.kh@osrueku &&&&&&&&&&&&&&&&&&&&&&&&&&&&& ftyk@{ks= &&&&&&&&&&&&&&&
fVIi.kh (Remarks)
Ø- _.knkrkvksa ds uke rFkk irs ns;rk vkjEHk gksus dh ysunsu dk fooj.k Lohd`r lhek cdk;k jkf”k [ _.k dk mi;ksx ,oa
(Name & address of rkjh[k (Date of incurring (Details of (Sanctioned (Outstanding
la- creditors ) liability) transaction) Limit) Amount)
iquHkqZxrku (Use of Loan &
repayment terms etc.)]

rkjh[k % ----------------------------
LFkku % ---------------------------- ¼vf/kdkjh ds gLrk{kj½
 cM+kSnk jktLFkku {ks=h; xzkeh.k cSad cSad fjdkWMZ ds fy,
vuqcU/k * Mh *
¼iz/kku dk;kZy; % vtesj½
'kk[kk@dk;kZy; &&&&&&&&&&&&&&&

'ks;j] izfrHkwfr;ksa] fMcsp

a j ,oa ikjLifjd fuf/k;ksa dh ;kstukvksa vkfn esa ysu&nsu n'kkZus okyk fooj.k] fnukad 31 ekpZ]---------

vf/kdkjh dk uke ¼dqy uke izFke½ &&&&&&&&&&&&&&&& ¼deZ-dwV la-½ &&&&&&&&& inuke &&&&&&&&&&&&&&&&&&&
Js.kh@osrueku &&&&&&&&&&&&&&&&&&&&&&& ftyk@{ks= &&&&&&&&&&&&&&
v½ D;k ikVhZ vkosnd dh foRr izkIr djus dk L=ksr
foRrh; o"kZ ds nkSjku 'ks;j]
fj'rsnkj gS vkSj
izfrHkwfr;ak] fMcsp
a j] ftl ikVhZ@QeZ ls
c½ D;k mlls vf/kdkjh vU; L=ksr vU; lacfa /kr rF;] tks fd
ikjLifjd fuf/k;ksa dh ysu&nsu fd;k x;k] O;fDrxr
{kerk ls ikVhZ ls dksbZ ls ¼L=ksr vf/kdkjh@deZpkjh n'kkZuk pkgrk gks
;kstuk,a vkfn esa fd, x, mldk uke cpr ls
laO;ogkj fd;k gS ;k fudV n'kkZ,a½
izR;sd ysu&nsu dk C;kSjk
Hkfo"; esa djus okyk gS\

eSa ,rn~}kjk ?kksf"kr djrk@djrh gwa fd mDr fooj.kh lgh gSA

rkjh[k % ----------------------------
LFkku % ----------------------------

¼vf/kdkjh@deZpkjh ds gLrk{kj½
 BARODA RAJASTHAN KSHETRIYA GRAMIN BANK
(HEAD OFFICE : AJMER)

Medical Fitness Report (At the time of Joining)

Affix passport
size photograph
duly attested
by Medical
Officer

Full Name Shri / Smt. / Miss ____________________________________S/o, W/o, D/o

______________________________________, address _________________________

_______________________________________________________________________

age _______ years, date of birth ____________, height ________ weight __________.
Blood Group___________.
COMPLAINT
_______________________________________________________________________

_______________________________________________________________________

Throat ______________ Eyes ______________ Temperature ____________________

Tongue ___________ Joints __________ Pulse ___________ Teeth ______________

Glands ___________ Resp ________________ Respiratory system ______________

Circulatory system __________________________________ Centro Urinary system

_____________________ Nervous system _________________________ Pregnancy

____________________ Identification Mark ________________________________

Remarks (regarding fitness) _____________________________________________

_____________________________________________________________________

Candidate Name
( )
Signature of the Candidate

Dated : ___________ Signature of the Doctor with Seal