PRATHAMA U.P.

GRAMIN BANK, HEAD OFFICE,

RAM GANGA VIHAR, MORADABAD
(PART- A)
(Name & Address of Referencee)

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Dear Sir,

Reg:- Shri -------------------------------------------------------------------- .

The above gentleman while applying for a job in the Bank has given your name as an
independent referee. We shall thank you to please answer the following queries and return
this form at an early date, in the enclosed envelope. The information given by you will be
treated as confidential.

Yours faithfully.

MANAGER (HRD)
(PART- B)

S.L. QUESTIONS ANSWERS

1. How long is the applicant known to you
2 Is he in any way related to you? If so state relationship
3 Have you ever employed him? If so, please state dates of his entering
and leaving your service and reasons for leaving.
4 Has he to your knowledge ever been:
(A) Dismissed from any employment,
(B) In pecuniary difficulties or under any debts or liabilities, and
(C) Convicted of any offence, Is so, please give details,
5 Has he suffered from any mental or physical disability? If so, please
give details.
6 Is he of sober habits? Do you believe him to be safe and proper person
for employment in the bank service?
7 Please give a frank opinion concerning his:
(A) Character and Reliability,
(B) Intelligence, ability and initiative for taking up independent
supervisory responsibility.

Place :------------------
(Signature & Address of referencee)

Date :------------------

Signature With Stamp-----------------------

Full Address ---------------------------------

Mobile No. ------------------------------

Landline No. ----------------------------
 PRATHAMA U.P. GRAMIN BANK, HEAD OFFICE,
RAM GANGA VIHAR, MORADABAD
(PART- A)
(Name & Address of Referencee)

-----------------------------------
----------------------------------
----------------------------------
----------------------------------

Dear Sir,

Reg:- Shri -------------------------------------------------------------------- .

The above gentleman while applying for a job in the Bank has given your name as an
independent referee. We shall thank you to please answer the following queries and return
this form at an early date, in the enclosed envelope. The information given by you will be
treated as confidential.

Yours faithfully.

Chief Manager (HRD)

(PART- B)

S.L. QUESTIONS ANSWERS

1. How long is the applicant known to you
2 Is he in any way related to you? If so state relationship
3 Have you ever employed him? if so, please state dates of his entering
and leaving your service and reasons for leaving.
4 Has he to your knowledge ever been:
(A) Dismissed from any employment,
(B) In pecuniary difficulties or under any debts or liabilities, and
(C) Convicted of any offence, Is so, please give details,
5 Has he suffered from any mental or physical disability? If so, please
give details.
6 Is he of sober habits?
Do you believe him to be safe and proper person for employment in the
bank service?
7 Please give a frank opinion concerning his:
(A) Character and Reliability,
(B) Intelligence, ability and initiative for taking up independent
supervisory responsibility.

Place :------------------ (Signature & Address of rerencee)

Date :------------------

Signature With Stamp-----------------------

Full Address ---------------------------------

Mobile No. ------------------------------

Landline No. ----------------------------
 INDEMNITY BOND WITH SURETY (For Officers)
(To be stamped as per State Stamp Rules)
This Indemnity is made and executed at ____________ on____ day of __________20__ by
Shri___________________ S/o Shri _________________ a permanent resident of
_____________________________________________ herein called “Employee”, the party of the First Part,
AND
Shri _______________________________S/o Shri _________________________ a permanent resident of
_____________________________________________________________________ hereinafter called
“Surety”, the party of the Second Part, in favour of Prathama U.P. Gramin Bank, a body corporate constituted
under the Regional Rural Banks Act, 1976 (21 of 1976) and Gazette Notification dated 22.02.2019 (effective
date 01.04.2019) issued by the Government of India, Ministry of Finance, Department of Economic Affairs
(Banking Division) having its Head Office at Moradabad hereinafter called “Employer Bank”.
The terms ‘Employee’, ‘Surety’ and the ‘Employer Bank’ unless repugnant to the context shall mean and
include their heirs, legal representatives, successors, executors and administrators.
WHEREAS the Employee has been selected for appointment as Officer in the service of the Employer
Bank.
WHEREAS an Offer of Appointment containing the terms and conditions of the appointment has already been
issued to the Employee vide letter No. __________ 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 ___________________ by the Employee.
WHEREAS one of the terms and conditions of the appointment is the Employee has to serve the Employer
Bank i.e. Prathama U.P. Gramin Bank for minimum period of three years after appointment, 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 Offer of Appointment subject to which the Employer
Bank has agreed to give appointment to the Employee, the Employee hereby undertakes to serve
the Employer Bank for a minimum period of three years.
2. 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 Employee under this agreement of indemnity. In case of breach of the terms of this
indemnity by the Employee and failure to indemnify the Bank, the Surety shall be jointly and
severally liable to pay the amount of Rs. 2,00,000/- (Rs. Two Lacs only) to Employer Bank
immediately on demand.
3. The Employee further agrees and undertakes 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. Two lakh and pay an
amount of Rs. 200000/- (Rs. Two lakh only) 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 employee at his/her place, and also on account of business loss
suffered/to be suffered by Employer Bank during intervening period. The employee and surety
agrees that assessment of liquidated damages as assessed at Rs. _____________are
reasonable, which they both agree to pay jointly and severally in case demand is made by the
Employer Bank.
4. Notwithstanding anything contained herein above, furnishing of this indemnity will not create any
right in favour of the Employee to continue in the service of Employer Bank for the aforesaid term
of three years, and the Employer Bank shall always have the right to take appropriate action
against the Employee 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 misconduct by the Employee.
5. 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.
IN WITNESS whereof, the EMPLOYEE and the SURETY have put their signatures in the
presence of the witnesses.
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.

1. WITNESS: EMPLOYEE SIGNATURE

NAME & ADDRESS: NAME & ADDRESS

2. WITNESS: SURETY SIGNATURE

NAME & ADDRESS: NAME & ADDRESS

 PRATHAMA U.P. GRAMIN BANK, HEAD OFFICE,
RAM GANGA VIHAR, MORADABAD

MEDICAL CERTIFICATE

A. TO BE FILLED IN BY THE EXAMINEE HIMSELF

Name ---------------------------------------------------- (Full Name in Block Letters)

Address ----------------------------------------------------
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1 Have you ever had any serious illness or

surgical operations?
2 Have you or has any member of your
family ever been under treatment for
tuberculosis?
3 Have you or has any member of your
family ever suffered from mental disease
fits or epilepsy or been treated in an
institution for any kind of these diseases?
4 Have you or has any member of your
family ever been under treatment for
trachoma?

State “NORMAL” – if not, give particulars of any departure from normal:

Husband/Single Man Wife/Single

Woman/Widow

Date of Birth-------------------------- Date of Birth ------------------------

Signature of the Examinee

 B. TO BE FILLED IN BY THE EXAMINING DOCTOR:

Max. Min. Max. Min.

A Heart
B Blood Pressure
C Lungs
D Nervous system
E Mental Condition &
Intelligence
F Digestive Organs
G Skelton-Bones & Joints
H Skin
I Hearing
J Sight
a) Without glasses R L R L
b) With glass (in worn)
K Genito Urinary Organ
L Is albumin or sugar
present in urine?
M Teeth
N Deformities

Height ______________ Weight ________________

_________________
(Signature of Examiner)

Remarks: In case where the Medical Examiner is unable to describe the examinee as being in
perfect health and development he should state the exact nature of the defect which he finds
and whether it is of a permanent or temporary nature.

I certify that I have this day examined the above named and that the results are as set forth
and I certify that in my opinion subject to any special observations under ‘Remarks’ the
above named is in good health and of sound condition and not suffering from any mental or
bodily defect.

Date ______________ (Signature of Examiner)

Address _______________________
______________________________
_______________________________
_______________________________
 POLICE VERIFICATION REPORT

I certify that following information is correct and complete to the

Photograph paste
best of my knowledge and belief. by candidate (same
as IBPS
application)
Attested by
authorized
signatory of police
station

S. No. Particulars Description

1. Full name
2. Father name
3. Present address (with
police station name)

4. Permanent address (with

police station name)

5. Period of present residence

6. Nationality

I have not been ever arrested/prosecuted/convicted in any criminal

case/activities by the court of law.

Signature of the applicant

Date :
Place :
Police Certification
The details as stated above are correct and the above person does not have any
criminal or any case registered or pending in any court of law.

He/She bears a good moral character.

Authorized Signatory
(Seal of police station)