APPLICATION FORM To The Asst./Dy.

/General Manager, Regional Office Vijaya Bank, ---------------------------------PLEASE AFFIX YOUR RECENT PASSPORT SIZE PHOTOGRAPH AND SIGN ACROSS

With reference to your advertisement in ________________ dated _______, I submit my application in the prescribed format. Name of the post applied for: PEON ST: OBC: GEN:

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

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

3. ADDRESS FOR CORRESPONDENCE:

Pincode: 4. DATE OF BIRTH : DD MM YY

5. AGE (As on 15.07.2011): __________ 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- 2011" and payable at Chennai.) Cash, Money Order, Postal Stamps/postal orders will not be accepted.

7. INDICATE BY MARK IN APPROPRIATE BOX: i) GENDER: MALE FEMALE

YES ii) Are you a widow?

NO

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

NO

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.______ OH iv) 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 HI VH

vi) Whether children/family members of those died in 1984 riots: YES NO

vi) Whether you belong to Minority community: If yes, please state the religion: ____________ vii) In case of SC/ST/OBC Candidate a) Name of the Caste/Tribe/Class b) Name of the state to which I belong viii) Married/Unmarried :

YES

NO

: _____________ : _____________

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

9. FATHERS/HUSBANDS NAME (indicate appropriately): Mr. 10. NATIONALITY : ____________________ 11. PLACE OF BIRTH: Place _______ 12. PERMANENT ADDRESS: Dist._________ State________

Pincode: 13. EDUCATIONAL QUALIFICATION (From VIII Standard onwards; as on 15.07.2011): Examination Passed Name of the Institution Month & Year %age studied of passing marks of

(If space is not sufficient, please attach separate sheet) 14. PARTICULARS OF EXPERIENCE, IF ANY: Name of the Period of Length of Nature of employer & nature of Service Service duties activities carried by Years Month performed them From To Remarks (Reason for leaving service)

(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) __________________ Read/Write/Speak (B) __________________ Read/Write/Speak (C) __________________ 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 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 Chennai. I undertake to abide by all the terms and conditions mentioned in the advertisement given by the Bank.

PLACE: ______________ DATE: _____________

SIGNATURE OF THE APPLICANT