APPLICATION FORMAT

APPLICATION FOR THE POST OF OFFICE ATTENDANT (MULTIPURPOSE) GROUP - "C" CADRE

(Fill all columns in legible capital letters in own handwriting and use "8.27 X 11.69" size paper) To THE ODISHA GRAMYA BANK HEAD OFFICE KOKILA RESIDENCY ANANT VIHAR, POKHARIPUT BHUBANESWAR - 751020

Paste your recent passport size photograph with signature across the photograph. Please retain three copies of the same photo for subsequent verification at the time of interview.

With reference to your advertisement, I submit my application in the prescribed format for the Post of Office Attendant (Multipurpose) Group - "C" Cadre 1 FULL NAME IN BLOCK LETTERS: (Leave one space blank between two parts of your name)

CONTACT NUMBER 2 FATHER'S / HUSBAND'S NAME 3 PERMANENT ADDRESS WITH PINCODE

STATE 4 ADDRESS FOR COMMUNICATION WITH PINCODE

PIN

STATE 5 GENDER (Please indicate by putting tick mark in the appropriate Box) MALE FEMALE

6 Are you a native / resident of Angul, Dhenkanal, Khurda, Nayagarh, Puri, Cuttack, Kendrapara, Jajpur, Jagatsinghpur, Balasore, Bhadrak, Keonjhar, Mayubhanj districts of Odisha? If yes, please indicate the name of the District Name of the District

(Please enclose attested Photocopy of the Nativity Certificate issued by a Revenue Officer not below the rank of Tahasildar with the application) 7 Information having registered the name in Employment Exchange in the State of Odisha. Sl Particulars

a Name of the Employment Exchange with complete address where name has been registered for Employment. b Registration No. c Valid upto (Please enclose attested Photocopy of the valid Employment Registration Certificate) 8 CATEGORY TO WHICH THE CANDIDATE BELONGS: (i.e. SC / ST / OBC / GEN ) (Please enclose attested photo copy of Caste Certificate) Name of the Caste / Tribe 9 EDUCATIONAL / PROFESSIONAL QUALIFICATION (As on 01-04-2013) Examination Passed Name of the University / Discipline / Stream Month & Year of Institution passing H.S.C +2 Graduation Post Graduation Others Please enclose attested photocopies of educational qualification Certificates.

% of Marks

10 DATE OF BIRTH DATE MONTH YEAR AGE (As on 01-04-2013 .. Years Months Days as per HSC Certificate) 11 PARTICULARS OF FEES (Demand Draft): Name and Address of Bank /Branch Date of Deposit Amount

Name of the Employer / Farm etc and the nature & details of activities carried out by the Employer

12 Particulars of previous employment including the present Occupation / joB if any: Length of Nature of Designation and rank Period of Service service duties if any From To

(Years / performed months ) in detail

Ramarks (Reason for leaving service)

13 INDICATE BY TICKING IN APPROPRIATE BOX (i) Are you an Ex-serviceman? YES

NO

In case of Ex-serviceman / Commissioned Officer / Police Officer / Other equivalent, speficy Date of Discharge: . Rank at person / last held Acting .. w.e.f .. Substantive .. w.e.f .. Whether you belong to Religious Minority Community? YES NO

(Please indicate by putting tick in the appropriate Box) If YES, please state the religion .. (ii) IN CASE OF PERSONS WITH DISABILITY OH HI (Please indicate by putting tick in the appropriate Box) Per centage of disability . (please enclose attested photo copy of Medical Certificate issued by Medical Board at District Level)

14 Language Known: (Please write the Language name) READ WRITE

SPEAK

15 Any other information 16 DECLARATION I hereby declare that all the statements made in this application are ture, complete and correct to the best of my knowledge and belief. I understand that in the event of my information being found false or incorrect at any stage or not satsifying the eligibility criteria according to the requirements of the relative advertisement, my candidature / appointment, for the said post is liable to be cancelled / rejected at any satge and if appointed, my services are to be cancelled / terminated. I have not been debarred from taking up the test / selction by any Bank; have not been convicted in any criminal case. I am willing to serve anywhere, if selected. I agree that the bank has the right to transfer me to any place at its discretion. I hereby agree that any legal proceedings in respect of any matter(s) or claims or disputes arising out of application and / or out of the said advdrtisement can be instituted by me only before the Courts / Tribunal Forums at Bhubaneswar and they also shall have the sole and exclusive jurisdiction to try the cause / dispute. I undertake to abide by all the terms & conditions mentioned in the advertisement given by the Bank and further communication / intimation / notification with regard to this recruitment. Place Date: Signature of the Applicant

BEFORE MAILING APPLICATION PLEASE CHECK THAT YOU HAVE FURNISHED THE FOLLOWING PARTICULARS: (i) Please ensure that you have registered your name with any employment exchange in the state of Odisha and submitted the photo copies of (1) Valid Employment Registration Certificate (2) Nativity Certificate issued by a Revenue Officer not below the rank of Tehsildar (3) Caste Certificate issued by competent authority (4) Educational Qualification certificates. Necessary certificates for Ex-serviceman, Persons with Disabilities are to be enclosed.

(ii)

The envelope is to be superscripted with the words "APPLICATION FOR THE POST OF OFFICE ATTENDANT (MULTIPURPOSE) GROUP "C" CADRE