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ON-LINE APPLICATION FOR RECRUITMENT OF OFFICER MMG SCALE-III,II,OFFICER JMG SCALE-I AND OFFICE ASSISTANT

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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 : Post : Post Code : Category : If physically challenged : Type of Disability : Percentage of Disability : Do you intend to use the services of a scribe (only for VI and OC both hands 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 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 candidate who had ordinarily been domiciled in Kashmir Division of the State of J&K during the period 1-1-1980 to 31-12-1989 ? : Nationality : Centre of Examination : Centre code : Application Fee / Postal Charges Details : Payment In: Transaction ID : Branch Name: Branch Code No. (SOL I.D.) : Deposit Date : Amount :

18895 VIKAS KUMAR PANDOLE Officer JMG Scale - I - Group "A" 03 SC NO NA NO -NO NO

NO NO NO INDIAN Rewa 11

UNION BANK OF INDIA AA262614 RGPV BHOPAL 58670 14-12-2011 50

Personal Details : Date of Birth : Age completed as on 31-03-2010 : Gender : Marital Status : Husband's Name/Father's Name : Mother's name : 24-02-1989 22 MALE Unmarried TULSIRAM PANDOLE LAXMI PANDOLE

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Address for Correspondence : MARATHA MOHALLA ATHNAIR DISTT BETUL MP 460110 District : State : Pin : Permanent Address : BETUL MADHYA PRADESH 460110 MARATHA MOHALLA ATHNAIR DISTT BETUL MP 460110 District : State : Pin : Contact Details: Phone Number : Mobile Number : Email ID : Qualification Details (as on 31.03.2010) : Exam Passed Degree / Diploma : Working Knowledge of Computers : Details of Computer Knowledge: Post Qualification work experience details (Start from present Employer) : Name of the Employer & Designation and Rank From(mm/yyyy) To(mm/yyyy) Nature of Reason for Leaving Years of Service (YY/MM) Nature of Employment Duties Performed Total Experience (in months) : Other Details : Would You like to undergo Pre-Exam Training (SC/ST/Minority) : If Yes ,Centre for Training : YES Rewa Languages Known Hindi ENGLISH Read YES YES Write YES YES Speak YES YES Name of the subject/stream Others-INDUSTRIALPRODUCTION YES MS OFFICE CCA DCA INTERNET Year of Passing 2010 % of Marks 70.19 Class/Grade First Class 9074502313 vpandole@gmail.com BETUL MADHYA PRADESH 460110

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 Madhya Pradesh and courts/ Tribunal/ forums at Madhya Pradesh 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: 14-12-2011 Signature of Applicant

VIKAS KUMAR PANDOLE

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