BRING BUSINESS, EDUCATION, DEVELOPMENT

AND
GOVERNMENT TO RURAL INDIA
Under the aegis of the National e-Governance plan of Rural Banking Development Authority of India

Application No 33 L

M/S SYNAPSE CSP channel partner application form for bc kiosk banking for any
query please call:- 01732361163 or write to: info@synapsecsponline.com
THIS KIT CONTAINS THE FOLLOWING FORMS:
FORM 1: - PERSONAL PROFILE
FORM 2: - INFRASTRUCTURE / FINANCE

(NOTE: Filling of both forms is mandatory. The information furnished by the applicants shall be treated in
strict confidence.)

DETAILS OF INVESTMENT TO BE MADE BY CHANNEL PARTNERS IN STOCKS

The investment to be made by Channel Partners is based on the District/state level partner, Details are as under
(a) Rural & Urban VLE Registration Charge: - Rs. 15600/-only
(b) District Level Channel Partner: - Rs 49800/- only
(c) State Level Channel Partner: - Rs 149800/- only

Mode of Payment: -
(1) By Mobile Banking/NEFT
(2) By UPI/PHONE PE/GOOGLE PAY/PAYTMT/Online transfer

Terms & Conditions: -

(1) This agreement is only valid for 5 years from the date of initial approval.
(2) Every channel partner will be awarded by 30% commission on every csp application form.
(3) Channel Partner will also get 35% Royalty on every transition from concerned CSP Centre.
(4) Channel partner is also responsible for any type of abnormality related to its concerned Bc centre.
(5) Local audit authority is also concerned with channel partner.
Declaration: -

I have read and understand all information/terms & conditions and signed this agreement

Date: - Applicant Signature

 FORM 1 PERSONAL PROFILE
PERSONAL DETAILS
NAME (IN FULL AND BLOCK LETTERS):
FATHER'S/HUSBAND'S NAME:
COMPLETE POSTALADDRESS:
CITY/TOWN DISTRICT:
PIN CODE STATE:
DATE OF BIRTH:
TELEPHONE No.: Off Resi. Mobile
Fax e-mail:
QUALIFICATIONS

DEGREE / DIPLOMA/CERTIFICATE UNIVERSITY/ INSTITUTION SUBJECTS YEAR OF PASSING

BUSINESS EXPERIENCE (if any)

NATURE OF NAME OF NATURE YEAR(TO) TURNOVER (Rs.Lac) PRODUCTS NO.OF

INVOLVEMENT ORGANIZATION BUSINESS EMPLOYEES

EXPERIENCE AS EMPLOYEE (if relevant)

ORGANIZATION DESIGNATION SALARY DRAWN YEAR (TO) NATURE OF MAIN PRODUCTS NO.OF
WORK EMPLOYESS

FAMILY DETAILS (Father, Mother, Spouse, Brother/s, Sister/s, Children)

NAME AGE RELATIONSHIP QUALIFICATIONS OCCUPATION

PLEASE MENTION IS BRIEF A FEW DETAILS ABOUT YOUR ACHIEVEMENTS, YOUR TYPICAL DAILY ROUTINE, YOUR
BUSINESS GOALS AND AMBITIONS.
DECLARATION
I We declare that the details and information provided by me /us herein above, are true to the best of my /our knowledge and belief
U
DATE:
PLACE………………………………………………………. Signature………………………………………………………………….
 FORM 2 - INFRASTRUCTURE I FINANCE
STRUCTURE OF THE BUSINESS ENTITY FOR CHANNEL PARTNERSHIP

Proprietorship Organization Private Limited Company

Partnership Firm Limited Company

Others (Please specify)

INVESTMENT CAPABILITY

(A) Rs.15600/- (B) Rs.49800/- (C) Rs.149800/-

(A, B, C are relevant if you would be interested in becoming a channel partner in multiple cities or in becoming a master distributor)

FINANCIAL STRENGTH (Please indicate the amount to be invested)

FROM OWN SOURCES

NAME AMOUNT AVAILABLE FOR INVESTMENT

(NOTE: Please check that the details are in tune with the investment required for the city chosen by you.)
*Subject to terms & conditions.
CHOICE OF DISTRICT/STATE FOR DISTRIBUTION PURPOSES
PROPOSED LOCATION WITHIN THE CITY
REASONS FOR CHOICE OF LOCATION
MENTION REASONS FOR INTEREST IN THIS BUSINESS
CURRENT INFRASTRUCTURE AVAILABLE_
WHETHER HAVING ANY PREMISES

IF YES, NATURE OF PREMISES Yes No

Owned Rented / Leased Single ownership Joint Multiple

PLEASE FURNISH DETAILS OF THE PREMISES

 CENTRALITY OF LOCATION & THE RATIONALE
(Please give details regarding location, proximity to industrial belt I educational institutions I residential localities and
the status of the neighborhood etc.)
DETAILS OF ADDITIONAL OFFICE INFRASTRUCTURE

Telephone: Yes No
Fax : Yes No
Internet : Yes No

Final Check list:-

1. Please provide only correct Information otherwise your application may be Canceled in future.
2. Please provide your Security money in above mention account only.
3. After filling application form please send it to under mention address: -
SYNAPSE BC
Mayapuri Phase II New Delhi,India
4. You can also submit your application form online on E-mail: - info@synapsecsponline.com

5. For any further query please contact our customer care executive.

DECLARATION
We declare that the details and information provided by me 1 us herein above are true to the best of my knowledge and
belief

DATE:

PLACE (Signature)
 BRING BUSINESS, EDUCATION, DEVELOPMENT
AND
GOVERNMENT TO RURAL INDIA
Under the aegis of the National e-Governance plan of Rural Banking Development Authority of India

VLE Registration Form under Rural Banking/Authority

Application No:– 33 L

Name of Vle ………………………………………………………………………………….

Paste your
Father/Husband Name ……………………………………………………………………………………………………….. Recent
Mother Name……………………………………. ..................................................... ……………………………. Passport Size
Photograph
Product for which VLE wants to apply: -

(a) Kiosk Banking (b) eGovernance

SBI Canara Bank (c) Account opening
PNB HDFC Bank (d) Booking
BOB IDBI Bank (e) Aadhaar & Pan
CBI Indian Bank (f) Loan under SGH Group
ICICI Kotak Bank (g) AEPS
BOI Name of Bank (Other)
Axis Bank

Permanent Address……………………………………………………………………………………………….
Contact Number.................................................. E-mail..........................................................................................
Are you in job .................................................................................................................................................... ?
Monthly Income from all sources..............................................................................................................................
Type of Property for CSP outlet...............................................................................................................................
Mode of Payment ……..........................................................................................................................................
Aadhaar no........................................................................ Pan no…………………………………………………
Account no......................................................................... Ifsc code........................................................................

Declaration: - Above mention all information about me are true in my knowledge and I declared that if found
any wrong information then Rural Banking Development Authority of India will not responsible for any type of
cancellation,

Date Your faithfully VLE

 Banking Development Authority (Bank Mitra Pvt. Ltd.)
Final Checklist for applying any product under Rural

1. Read the Terms & Conditions of every product of SYNAPSE CSP BC carefully on Brochure
2. Before Installation of any software please read the file How to Install or call:- 01732361163
3. Fill up the application-form carefully.
4. Essential documents -
(a) ID Proof
(b) Address Proof
(c) Demand Draft (For. trading Account)
5. Complete fill-up application Form
6. Please send the application form by registered post or speed post only.
7. Please de not install any software without prior information from SCA
8. All software is locking with Password for unblock please call:- 01732361163
9. All Software are procreated by End-user license of Rural Banking Development Authority, so do
Not make any type of amendment and share with anyone.
10. For more information please visit www.synapsecsponline.com
11. For any type of information please write to info@synapsecsponline.com

Declaration:- Please provide only correct information and attached all essential document with your application
form ,Rural Banking Development Authority will not Responsible for any type of cancellation due to missing of
any Document.
With Best Regard
Pro. S Pattnaik
Chairman & Managing Director