lkk{;kad u qkez nks izfr;ksa ea½ - uttarakhand gramin · pdf filepage 1 of 21 lkk{;kad...

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Lkk{;kadu QkeZ (nks izfr;ksa esa½ Lkk{;kadu QkeZ esas >wBh lwpuk nsuk ;k okLrfod tkudkjh fNikuk v;ksX;rk gksxh vkSj blls vH;FkhZ cSad esa fu;qfDr ds fy, vuqi;qDr gks ldrk gSA ;fn O;fDr dh lsok ds nkSjku fdlh Hkh le; ;g rF; laKku esa vkrk gS fd lk{;kadu QkeZ esa >wBh lwpuk nh x;h gS ;k dksbZ okLrfod tkudkjh fNikbZ x;h gS rks mldh lsok lekIr dj nh tk;sxhA

1 iwjk uke ¼ fgUnh esa ½ Full Name in English (In capital letters) 2 firk dk uke 3 ekrk dk uke 4 ifr@iRuh dk uke 5 jk’Vªh;rk Lo;a -------------------------------------firk ------------------------------------------------------

Ekkrk ------------------------------------ifr@iRuh---------------------------------------------- 6 /keZ 7 Tkkfr (SC/ST/OBC/GENERAL) 8 “kSf{kd ;ksX;rk ¼izek.k lfgr½

mRrh.kZ ijh{kk iwjs irs lfgr fo|ky;@dkyst@ fo”o fo|ky; dk uke mRrh.kZ djus dk o’kZ a gkbZLdwy (10th) b bUVjehfM,V (10+2) c Lukrd d ijkLukrd e vU; (;fn gks)

9 O;kolkf;d ;ksX;rk 10 tUe LFkku 11 tUe frfFk 12 orZeku iwjk irk

13 LFkk;h irk

14 ewy vf/kokl (Place of Domocile) 15 eksckby uEcj @ Qksu uEcj 16 bZ&esy vkbZ0 Mh0 17 CyM xzqi 18 iSu (PAN) 19 vk/kkj uEcj 20 ernkr igpku i= uEcj 21 Mªkbfoax ykblsal uEcj 22 Hkfo’; fuf/k [kkrk dzekad (UAN) 23 Hkfo’; fuf/k [kkrs gsrq ukferh dk

fooj.k uke-------------------------------------------------lEcU/k-----------------------------------

24 xzsP;qVh gsrq ukferh dk fooj.k uke-------------------------------------------------lEcU/k-----------------------------------

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25 mu LFkkuksa dk fooj.k ¼fuokl dh vof/k lfgr½ tgka vkius fiNys ikWap o’kZ ds nkSjku fdlh ,d le; esa ,d o’kZ ls vf/kd le; rd fuokl fd;k gSA dc ls dc rd iwjk vkoklh; irk

26 ;fn vki fdlh le; fu;ksftr jgs gSa rks O;kSjk nsa&

/kkfjr in dk uke dk;Z dk fooj.k vof/k dc ls dc rd

dk;kZy; QeZ ;k laLFkk dk iwjk irk dk;Z NksMus dk dkj.k

27- D;k vkidks dHkh fdlh vijk/k ds fy;s U;k;ky; }kjk fxj¶rkj fd;k x;k ;k utjcUnh esa j[kk x;k ;k vkc)@tqekZuk@nks’kfl) fd;k x;k ;k la?k yksd lsok vk;ksx us viuh ijh{kk p;uksa esa cSBus ls oftZr@v;ksX; ?kksf’kr fd;k gS ;k fdlh izkf/kdj.k@laLFkk }kjk fdlh ijh{kk esa cSBus ls fooftZr@fofu’dklu fd;k x;k gS ;fn mÙkj gka gS rks utjcUnh tqekZuk] nks’kfl) n.Mkns”k vkfn ds ekeys dk iwjk C;kSjk fn;k tkuk pkfg;s& -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- QksVks LogLrk{kfjr fu”kkuh vxwaBk uewuk gLrk{kj Affix Photo

eSa izekf.kr djrk gwWa fd tgka rd eq>s irk vkSj fo”okl gS iwoksZDr lwpuk lgh rFkk iwjh gSA eq>s ,slh fdUgh ifjfLFkfr;ksa dh tkudkjh ugh gS ftlls cSad esa fu;kstu ds fy, esjh mi;qDrrk esa deh gks] eq>s cSad }kjk fu/kkZfjr fdlh Hkh i)fr ls fdlh Hkh le; ¼rRdky@fudV Hkfo’; esa½ esjs vkosnu i= ess esjs }kjk fn;s x;s fooj.k ds lEcU/k esa esjs iwoZor dh ¼iqfyl tkap lfgr½ tkap fd;s tkus esa dksbZ vkifÙk ugh gS@ ugh gksxhA

vH;FkhZ ds gLrk{kj fnukad %------------------------------------- LFkku % --------------------------------------

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oSokfgd izkfLFkfr dh ?kks’k.kk vuqlwph A

[fofu;e 5¼4½¼ii½ ns[ksa]

izR;sd vf/kdkjh ;k deZpkjh ls izFke fu;qfDr ds le; izkIr fd;k tkus okyk ?kks"k.kk &i=A

1- eSa] Jh@Jherh@dq- ----------------------------------------------------------------------------------------------------------------------------------------iq=@iRuh@iq=h------------------------------------------------------------------------------------------------------------------------------------ fuEukuqlkj ?kks"k.kk djrk@djrh gw¡A

¼I½ eSa vfookfgr@fo/kqj@fo/kok gw¡A

¼II½ eSa fookfgr gw¡ vkSj esjs lkFk dsoy ,d thfor ifr ;k iRuh gSA

¼III½ eSaus ,sls O;fDr ls mlds ifr ;k iRuh ds thfor jgrs gq, fookg fd;k gSA eq+>s uhps fn;s

x, vk/kkj ij NwV eatwj dh tk,A NwV dh vuqefr dk vkosnu layXu gSA

vk/kkj------------------------------------------------------------------------------------------------------------------------------------------

2- eSa lR;fu"Bk ls izfrKku djrk@djrh gw¡ fd mi;qZDr ?kks"k.kk LkR; gS vkSj eSa le>rk@le>rh gwW a fd esjh fu;qfDr ds i'pkr~ bl ?kks"k.kk ds vlR; ik, tkus ij eSa lsok ls c[kkZLr fd, tkus ds fy, mRrjnk;h jgw¡xk@jgw¡xhA

Hkonh;]

¼vf/kdkjh@deZZpkjh ds gLrk{kj½ iwjk uke------------------------------------------------

inuke--------------------------------------------- fnukad- ----------------------------------------- LFkku-----------------------------------------------

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fu”Bk ,oa xksiuh;rk dh ?kks”k.kk vuqlwph 2

¼fofu;e 19 ns[ksa½

eSa ---------------------------------------------------------------------------------------------?kks”k.kk djrk@djrh gwa fd

eSa] mRrjk[k.M xzkeh.k cSad ds vf/kdkjh @deZpkjh ds :i esa vkSj mDr cSad esa esjs }kjk

/kkfjr dk;kZy; ls lacaf/kr ;k fLFkfr ls lac} eq>ls visf{kr drZO;ksa dks lR;fu”Bk rFkk

loksZRre dq’kyrk ls fu”ikfnr vkSj iwjk d:axk@d:axhA

eSa vkxs ?kks”k.kk djrk@djrh gwa fd eSa mDr cSad ds dk;ksZa ls lEcfU/kr dksbZ lwpuk ;k mDr

cSad ds lkFk Mhy djus okys fdlh O;fDr ls lEcfU/kr fdlh dk;Z ds ckjs esa dksbZ lwpuk

mlds fy, fof/kd :i ls vik= O;fDr dks u rks izdV d:axk@d:axh vkSj u gh ,slk

fd, tkus ds fy, fdlh O;fDr dks fujh{k.k djus ds fy, vuqKkr d:axk@d:axh vkSj u

rks mDr cSad ds vf/kdkj esa fdlh cgh ;k bysDVªkfuDl nLrkost vkSj u gh mDr cSad ds

dkjksckj ls lEcU/kh ;k mDr cSad ds lkFk Mhy djus okys fdlh O;fDr ds fdlh dkjksckj

dk fujh{k.k djus dh vuqKk iznku d:axk@d:axhA

vf/kdkjh@deZpkjh ds gLrk{kj iwjk uke-------------------------------------------- inuke-----------------------------------------------

esjs le{k gLrk{kfjr& fnukad%------------------------------------- iwjk uke--------------------------------------- LFkku%--------------------------------------- inuke---------------------------------------- fnukad%--------------------------------------- LFkku------------------------------------------

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vf/kokl dh ?kks"k.kk vuqlwph III

QkeZ [k ¼fofu;e 73 ns[ksa½

LFkku %------------------------------------------

fnukad %---------------------------------------

1- eSa ---------------------------------------------------------------------------------v/kksgLrk{kjh] mrjk[k.M xzkeh.k cSad dh

lsok esa fu;qfDr ds ckn ,rn~}kjk ?kks"k.kk djrk@djrh gw¡ fd-----------------------------------------------------------------¼LFkku½ ---------------------------------------------------------------------------------- ¼ftyk½ esjk fuokl LFkku gSA

2- * mi;qZDr LFkku esjh tUeHkwfe gSA

;k

* mi;qZDRk LFkku esjh tUeHkwfe ugha gSA esjh tUeHkwfe---------------------------------------------------¼LFkku½--------------------------------------------------- ¼ftyk½ gS ijUrq--------------------------------------------------------------------¼LFkku½ dks fuEufyf[kr dkj.kksa ls viuk fuokl LFkku ?kksf"kr fd;k x;k gSA

gLrk{kj

iwjk uke-------------------------------------------------------------------------------------------------

inuke vkSj fu;qfDr dh izdfr------------------------------------------------------

fu;qfDr dh rkjh[k-------------------------------------------------------------------------------

*tks ykxw u gks mls dkV nsaA

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Hkz’Vkpkj fuokj.k vf/kfu;e 1958 dh tkudkjh v/;{k@egkizcU/kd] mRrjk[k.M xzkeh.k cSad] nsgjknwu]

egksn;@egksn;k]

eq>s tkudkjh gS fd Hkkjrh; n.M lafgrk dh /kkjk&21 esa nh xbZ yksd lsod ‘kCn

dh ifjHkk”kk lkafof/kd fuxeksa ds deZpkfj;ksa dks mlesa lfEefyr djus ds mn~ns’; ls n.M

fof/k la’kks/ku vf/kfu;e 1958 ds fucU/kksa ds vUrZxr foLrr dj nh xbZ gS] rnuqlkj

cSad ds lHkh vf/kdkjh@deZpkjh Hkz”Vkpkj fuokj.k vf/kfu;e vkSj yksd lsodks ls lEcfU/kr

fdlh vU; fof/k ds {ks= esa vkrs gSA

LFkku----------------------------------------------- fnukad----------------------------------------------

¼vf/kdkjh@deZpkjh ds gLrk{kj½ Ukke-----------------------------------------------------

Iknuke-----------------------------------------------

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fu;qfDr ds le; vH;FkhZ }kjk fn;k tkus okyk ?kks’k.kk i= v/;{k@egkizcU/kd] mRrjk[k.M xzkeh.k cSad] nsgjknwu]

eSa] v/kksgLrk{kjh ------------------------------------------------------- lqiq=@lqiq=h Jh ---------------------------------------------------- ,rn~}kjk

?kks”k.kk djrk gwa fd eSa dsoy ifjoh{kk/khu ds :i esa mRrjk[k.M xzkeh.k cSad dh lsok vkjEHk dj jgk gwWa

vkSj eq>s tc rd vkSipkfjd :i ls LFkk;h deZpkjh ugh cuk fn;k tkrk] eaS mDr in ij cSad dh lsok

djrk jgwaxk rFkk cSad ds lsok fu;eksa ds vuqlkj ifjoh{kk/khu ds :i esa esjh lsok,a ftlds fy, eS

izfrekg osru@ikfjJfed izkIr djrk gwa] fdlh Hkh le; fcuk dkj.k crk,] lsok lekfIr dh frfFk rd

ds osru dk Hkqxrku djds cSad dh bPNkuqlkj rRdky lekIr dh tk ldrh gSA

eS ;g Hkh ?kks”k.kk djrk gwa fd eSa mRrjk[k.M xzkeh.k cSad dh fdlh Hkh ‘kk[kk@dk;kZy; ij dk;Z djus

dks lg”kZ rS;kj gwa vkSj eq>s cSad esa fu;qDr fd;s tkus ij eSa dgha Hkh LFkkukUrfjr fd, tkus ij eSSa fcuk

fdlh ‘krZ ;k vkifRr ds cSad }kjk tkjh funsZ’kksa dk vuqikyu d:axkA

eSa ;g Hkh ?kks”k.kk djrk gwa fd u rks eS mUeqDr fnokfy;k gwa] u gh eq>s dHkh fnokfy;k ?kksf”kr

fd;k x;k gS] u gh eSus dHkh Hkqxrku fuyfEcr fd;k gS ;k vius ysunkjksa ds lkFk le>kSrk fd;k gS

vFkok u gh eq>s uSfrd v/kerk okys fdlh vijk/k esa fdlh n.M U;k;ky; }kjk nks”kfl} fd;k x;k

gSA ¼vf/kdkjh@deZpkjh ds gLrk{kj½ Ukke------------------------------------------- Iknuke--------------------------------------

LFkku------------------------------------------ fnukad -----------------------------------------

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LVkQ lEcU/kh ds ckjs esa lwpuk v/;{k@egkizcU/kd]

mRrjk[k.M xzkeh.k cSad]

nsgjknwu

egksn;]

eSa ?kks”k.kk djrk@djrh gwa fd orZeku esa mrjk[k.M xzkeh.k caSd dh fdlh ‘kk[kk @ dk;kZy; esa lsok dj jgs dksbZ Hkh LVkQ lnL; esjs lEca/kh ugha gSA vFkok cSad ds ‘kk[kk @ dk;kZy; ds eq>ls lEcfU/kr deZpkfj;ksa dk C;kSjk fuEufyf[kr gS %& dzekad lEcfU/kr LVkQ dk uke inuke ‘kk[kk@dk;kZy; lEcU/k

¼vf/kdkjh@deZpkjh ds gLrk{kj½ Ukke----------------------------------------------------- Iknuke-----------------------------------------------

LFkku------------------------------------------ fnukad -----------------------------------------

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fiNys fu;ksDrk ¼fu;ksDrkvksa½ ls izkIr fd, tkus okyh fjiksVZ dk QkeZ

1- vH;FkhZ dk uke------------------------------------------------------------------------------------------------------------------------------------------ 2- vof/k ftlds fy, vH;FkhZ vkidh dEiuh@

QkeZ@foHkkx esa fu;ksftr FkkA-------------------------------------------------------------------------------------------------------------------- 3- mldh lsokof/k ds nkSjku mldk vkpj.k--------------------------------------------------------------------------------------------

4- D;k vH;FkhZ vc Hkh lsok esa gS ;fn ugh rks c[kkZLrxh@

lsokeqDr@R;kxi= dk dkj.kA-------------------------------------------------------------------------------------------------------------- 5- D;k mldh fiNyh lsok ds lEcU/k esa dksbZ ,slh ckr gS

ftlls og cSad dh lsok ds fy, v;ksX; gks \------------------------------------------------------------------------------------------------- 6- D;k vH;FkhZ vkidk lEcU/kh gS \----------------------------------------------------------------------------------------------------------

LFkku--------------------------------------------- fnukad %-----------------------------------------

¼fu;ksDrk ds gLrk{kj rFkk uke½ inuke %----------------------------------------------- dEiuh@QeZ@foHkkx dk uke %

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

irk%------------------------------------------------------------- -------------------------------------------------- uksV% fiNys fu;ksDrk dh NOC / iwoZ fu;kstu R;kxi= vfHkLohdfr i= layXu djsaA

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vH;FkhZ }kjk fn;s tkus okys nks funsf”k;ksa ds uke

v/;{k@egkizcU/kd] mRrjk[k.M xzkeh.k cSad] nsgjknwu]

egksn;]

vkids i= fn0---------------------------------esa okafNr nks funsf’k;ksa] tks izfrf”Br O;fDr gSa] Hkkjr ds fuoklh gSa vkSj fiNys dqN o”kksaZ ls eq>s vkSj esjs pfj= ds ckjs esa tkurs gSa] fdUrq esjs lEcU/kh ugh gSa ;k mRrjk[k.M xzkeh.k cSad ds deZpkjh ugh gSa ds uke fuEuor~ izLrqr fd;s tkrs gSaA

1- uke ------------------------------------------------------------------------------ inuke-------------------------------------------------------------------------- irk--------------------------------------------------------------------------------

2- uke ------------------------------------------------------------------------------

inuke-------------------------------------------------------------------------- irk--------------------------------------------------------------------------------

3- fiNys@orZeku fu;ksDrk] ;fn dksbZ gks] dk irk% uke irk

Hkonh;] ¼vf/kdkjh@deZpkjh ds gLrk{kj½

uke ------------------------------------------------------ inuke--------------------------------------------------- LFkku------------------------------------------- fnukad -----------------------------------------

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nks funsf”k;ksa ls izkIr dh tkus okyh fjiksVZ dk QkeZ * * nks vyx-vyx izfr;ksa esa vH;FkhZ dk uke ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

in ftlds fy;s vkosnu fd;k gS ----------------------------------------------------------------------------------------------------------------------------- 1- D;k vH;FkhZ vkils ifjfpr gS\ gka@ugh

2- ;fn gka rks di;k ifjp; dh vof/k dk mYys[k djsaA o"kZ --------------ekg--------------

3- D;k tgka rd vkidks irk vkSj tkudkjh gS&

mls dHkh U;k;ky; }kjk fxj¶rkj fd;k x;k@vfHks;kstu fd;k x;k@ut+jcUnh esa j[kk x;k gS ;k nks”kfl}

fd;k x;k gSA gka@ugh

4- D;k vH;FkhZ ds ifjokj ls ifjfpr gS \ gka@ugh

5- D;k vH;FkhZ ds ifjokj ds fdlh lnL; dks U;k;ky; }kjk fxj¶rkj fd;k x;k gS@ut+jcanh esa j[kk x;k gS

;k nks”kfl} fd;k x;k gSA gka@ugh

6- D;k vkidks fdUgh ,slh ifjfLFkfr;ksa dh tkudkjh gS ftuls vH;FkhZ cSfdax lsok esa fu;qfDr ds fy, vuqi;qDr gks gka@ugh

7- D;k vH;FkhZ vkidk lEcU/kh gS \ gka@ugh

eSa izekf.kr djrk gwa fd tgka rd eq>s irk ,oa fo’okl gS mi;qZDr lwpuk lgh gS vkSj Jh@Jherh@dqekjh ---

------------------------------------------------------- dk uSfrd pfj= vPNk gSA gLrk{kj LFkku-------------------------- uke----------------------------------------------------------------- fnukad----------------------------- inuke------------------------------------------------------------- eksckby ua0--------------------------------------------------- iwjk irk-------------------------------------------------------------

-------------------------------------------------------------------------- -------------------------------------------------------------------------- funs”kh ds irs ds lk{; ds :Ik esa Loizekf.kr QksVks vkbZ0Mh0 ¼;Fkk vk/kkj dkMZ@ernkrk igpku i=@Mªkbfoax ykblsal vkfn½ dh Nk;k izfr layXu djsaA

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v/;{k@egkizcU/kd] mRrjk[k.M xzkeh.k cSad] nsgjknwu]

egksn;]

¼vf/kdkjh@deZpkjh }kjk gLrk{kj fd;k tkus okyk i= ftlus izfrHkwfr&tek dj nh gSA½

fnukad --------------

eSa ,rn}kjk vfHkLohdr djrk gwa fd cSad dh lsok vf/kdkjh@deZpkjh ds :i esa viuh fu;qfDr ds lEc/k esa eSus :i;s nks gtkj ek= dh udn izfrHkwfr dh jkf’k tek dh gS] tks Lo;a esjs vkSj ‘kk[kk izcU/kd] nsgjknwu ds la;qDr uke ls vkidh nsgjknwu ‘kk[kk esa fo’ks”k lko/kh [kkrs esa tek dj nh xbZ gS vkSj tks esjs vPNs vkpj.k rFkk lR; fu”Bk ds fy, rFkk fdlh Hkh le; izoRr ijEijk] izFkk] dk;Zfof/k;ksa ,oa vuqns’kksa ds vuqlkj cSad ds fu;kstu esa jgrs gq, esjs }kjk drZO;ksa dks lko/kkuhiwoZd vkSj fu”BkiwoZd iwjk djus ds fy, izfrHkwfr ds :i esa jgsxhA

eSa ;g Hkh iqf”V djrk gwa fd esjh vfHkj{kk esa j[kh tkus okyh udn ewY;oku oLrqvksa vkSj izfrHkwfr;ksa dh vfHkj{kk lqj{kk vkSj =qfVghurk ds fy, eSa mRrjnk;h gksÅaxk rFkk esjs }kjk tek dh xbZ izfrHkwfr ;k mldh jkf’k dk fopkj fd, fcuk esjh vksj ls fd, fdlh Hkh dk;Z] pwd vkSj O;frdze ds fy, eS O;fDrxr :i ls ftEesnkj gksÅaxk rFkk ftl vof/k ds fy, eq>s ,slh udn eqY;oku oLrq,a vkSj izfrHkwfr;ka lkSaih tk;sxh] ml vof/k ds nkSjku ,sls dk;ksZ pwd vkSj O;frdze ds dkj.k cSad dks gksus okyh fdlh gkfu ;k {kfr ds fy, eSa cSad dks {kfriwfrZ djus dk opu nsrk gwaA

iwoZorhZ ckrksa dh O;kidrk ij izfrdwy izHkko Mkys fcuk] eSa ;g iqf”V djrk gwa fd jksdM+ foHkkx

esa deZpkfj;ksa dh fofHkUu Jsf.k;ksa dks mRrjnkf;Roksa ds vkoaVu] fu/kkZj.k vkSj fu;r djus ds fy, cSad esa le;≤ ij izHkkoh jksdM foHkkx iz.kkyh ,oe~ izfdz;k ds izko/kkuksa ds vuqlkj esjs }kjk fxus x;s ;k iqu% fxus x;s uksV o flDds ds ewY;] ifjek.k ,oe~ xq.koRrk ds fy, cSad ds izfr mRrjnk;h gksÅxka] ckotwn blds fd ;s uksV o flDds fdlh le; ,sls fdlh vU; deZpkjh dh okLrfod vfHkj{kk esa jgs gks] ftUgs cSad }kjk ,slh vfHkj{kk esa ysus ds fy, vf/kdr fd;k x;k gksA

Hkonh;] ¼vf/kdkjh@deZpkjh ds gLrk{kj½ Ukke------------------------------------------------------ Iknuke----------------------------------------------- LFkku------------------------------------------ fnukad -----------------------------------------

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&‘kk[kk ds iz;ksx gsrq&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& izekf.kr fd;k tkrk gS fd izfrHkwfr tek jkf’k :0----2000@&¼:i;s nks gtkj ek=½ fnukad------------------------------dks gekjh ‘kk[kk esa tek dh x;hA gLrk{kj ¼eksgj lfgr½ ‘kk[kk izcU/kd]& ‘kk[kk nsgjknwu

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UTTARAKHAND GRAMIN BANK, H.O.-DEHRADUN PERSONAL STATEMENT OF THE CANDIDATE

TO BE FILLED IN BY THE CANDIDATE BEFORE PRESENTING THE FORM TO THE MEDICAL OFFICER

1. Name in full (Surname first) ……………………………………………………………..

2. Category of post ………………………………………………………………………

3. Address .…..……………………………………………………….…………..

4. Date of Birth ………………………………………………………………….………

5. Married/Single ………..……………………………………………………….……..

6. Personal History ….….…………………………………………………………….…..

A. History of Bleeding from Gastro-Intestinal Tract, Gastric or duodenal Ulcers,

Appendicitis, internal Piles, Fistula, Typhoid, Jaundice etc. Give details:-

……………………………………………………………………………………………………

………………………………………………………………………………………………….…

B. History of Asthma, Tuberculosis, Splitting of blood, Pleuresy Breathlessness etc.

Give details:

……………………………………………………………………………………………….……

………………………………………………………………………………………………….…

C. History of Palpitation, Fainting Spells, pain in the chest, Breathlessness of Exertion,

Cyanosis, Rheumatic fever with joint pains, Swelling of legs/face etc. Give details:-

……………………………………………………………………………………………….……

………………………………………………………………………………………………..……

D. History of Bleeding Urinary Tract, painful urination, passing of stones of gravel in

Urine etc. Give details:-

…………………………………………………………………………………………………..…

………………………………………………………………………………………………..……

E. History of Fits, Paralysis, Neurasthenia, Nervous Breakdown etc. Details to be given:- ………………………………………………………………………………………………….…

……………………………………………………………………………………………….……

F. History of Leprosy, extensive generalized allergic dermatitis, Leucoderma, Veneral

disease etc, Give details:-

……………………………………………………………………………………………….……

………………………………………………………………………………………………….…

G. Have you suffered from defects in hearing or eye sight? Give details:-

……………………………………………………………………………………………….……

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H. Details of serious illness/injuries sustained by accident or otherwise: Give details:

……………………………………………………………………………………………………

………………………………………………………………………………………………….…

I. Details of surgical operations undergone:

………………………………………………………………………………………………….…

……………………………………………………………………………………………….……

J. Is their any other item in your medical history which you have not already mentioned?

…………………………………………………………………………………………….………

………………………………………………………………………………………………….…

7. Family History:

(i) Heart disease and Hypertension:

(ii) Tuberculosis:

(iii) Kidney Disease:

(iv) Cancer

(v) Any other serious ailments:

8. For Female Candidates only:

(i) Menstrual History: Regular/Blood History

(ii) Date of L.M.P.:

(vi) Any evidence of pregnancy:

(vii) History of diseases of Uterus

Cervix, Ovaries or Breasts:

I hereby declare that the above statements are correct to the best of my knowledge and

that incorrect/suppressed information will render me liable for termination of my service in

the bank.

Affix Photo

Thumb impression Signature

Photo, Thumb impression & Signature of Sh./Smt./Km…………………………… verified

Signature of the Medical examiner with stamp Place……………………………………… Date--……………………………………..

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REPORT OF MEDICAL EXAMINATION

Name of the Candidate: …………………………………..………………………………………….

Category of the post: ………………………………………………………………………………....

1. General Development: Good……………….Fair……….………….Poor………..………….

Nutrition Thin……….……….Average………..…….Obese………….………

Best weight………………………………………..When………………………………...

Any recent change in weight……………………………Temperature……………….………

Girth of chest:

(i) After full inspiration

(ii) After full expiration

2. Skin: Any obvious disease

3. Eyes:

(a) Whether the vision is normal: If not, is it capable of being: Corrected to 6/6 with glasses (not with contact lenses)

Yes/No Yes/No

(b) If the candidate was referred To an eye-surgeon what are Surgeon’s observations in respect of the following:

(1) Any disease

(2) Night blindness

(3) (Defect in colour vision

(4) Field vision

(5) Visual acuity

(6) Fundus examination

Acuity of Vision Naked With Glasses Strength of Glasses

Eyes Sph. Cyl. Axis

Distant Vision

R.E.

L.E.

of 21

Near vision

R.E.

L.E.

Hypermetropia

(Manifest)

R.E.

L.E.

4. Ears: Inspection…………………………………………………………………

Hearing: Right Ear………………………………………………………………

Left Ear…………………………………………………………………………..

5. Glands: …………………………………..…Thyroid…..……………………….

6. Conditions of Teeth: …………………………………………………………….

7. Respiratory System:

Does physical examination reveal anything abnormal in the respiratory organs? .....

If yes, explain fully………………………………………………………………

8. CIRCULATORY SYSTEM:

(a) Heart : Any organic lesions? ………………………………………………

Pulse Rate : ……………………………………………………………….

(b) Blood Pressure:

Systolic …………………………………………………………………….

Diastolic ……………………………………………………………………

9. Abdomen: Girth………………………………. Tenderness…………………

…………………………………………………. Hernia………………………...

(a) Palpable: Liver ……………………………Spleen ………………………

Kidneys ………………………………….. Tumors …………...................

(b) Hemorrpooids …………………………… Fistula…………………........

10. NERVOUS SYSTEM : Indication of nervous or mental disabilities

11. LOCO-MOTOR SYSTEM: Any abnormality

12. GENITO URINARY SYSTEM: Any evidence of Hydrocele, Varicoecele etc...

Urine Analysis:

(a) Physical appearance (b) Sp. Gr.

(c)

(e)

Albumin

Casts

(d)

(f)

Sugar

Cells

13. REPORT OF X-RAY BLOOD EXAMINATION OF CHEST:

14. REPORT OF THE BLOOD EXAMINATION:

15. Is there anything in the health of the candidate likely to render

him/her unfit for the efficient discharge of his/her duties in

the service for which he/she is a candidate ?

16. The Medical Examiner should record the findings under one of the

following categories:

(i) Fit

(ii) Unfit on account of

NOTE: In the case of a female Candidate, if it is found that she is pregnant, she should be declared temporarily unfit.

Signature of the Medical Examiner with seal. Place………………………………………… Name: ……………….…………………..

Date………………………………………… Designation: …………………………….

INDEMNITY BOND WITH SURETY (Officer) (On Rs.100/-Non Judicial Stamp Paper)

This Indemnity is made and executed at____________________ on this______________ day of ________ 20_____ by Shri/Smt/Kum _________________________________ S/o;W/o;D/o Shri __________________________ a permanent resident of________________________________ _______________________________hereinafter called “Employee”, the party of the first part,

AND (i)Shri/Smt/Kum ________________________ S/o;W/o;D/o Shri _________________________ a permanent resident of ________________________________________________________& (ii)Shri/Smt/Kum ________________________ S/o;W/o;D/o Shri _________________________ a permanent resident of __________________________________________________________ hereinafter called “Sureties”, the party of the second part, in favour of Uttarakhand Gramin Bank,having its Head Office at 18, New Road, Dehradun (Uttarakhand)-248001 , a body corporate constituted under the Regional Rural Banks Act, 1976 (21 of 1976) and established vide Gazette Notification dated 01.11.2012 issued by the Government of India, Ministry of Finance, Department of Economic Affairs (Banking Division) hereinafter called “Employer Bank”. The terms ‘Employee’, ‘Sureties’ 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 SCALE I 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 which has been duly signed and accepted by the Employee. WHEREAS one of the terms and conditions of the appointment is the Employee has to serve the Employer Bank viz. Uttarakhand Gramin Bank for a minimum period of TWO 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 TWO years. 2. The party of the second part i.e. (i)______________________& (ii)____________________ agree to stand as Sureties 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 his/her failure to indemnify the Bank, the Sureties shall be jointly and severally liable to pay Rs. 100,000/-(Rupees One Lac 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/her leading to termination of his/her service as per rules/regulations by the Employer-Bank, he/she shall be liable to pay a sum of Rs.100000/-(Rupees ONE LAC only) which the employee and the sureties 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 TWO 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. 5. The amount specified above shall constitute a debt owing to the Employer-Bank and shall be recoverable from the Employee and the Sureties jointly and severally. IN WITNESS whereof, the EMPLOYEE & the SURETIES 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 read and understood the contents/terms of this Agreement. SIGNATURE EMPLOYEE: NAME & ADDRESS: Signed and delivered by the Party of the second part i.e. the Sureties having read and understood the contents/terms of the Agreement_____________________________________

SIGNATURE SURETY 1 SIGNATURE SURETY 2:

NAME & ADDRESS: NAME & ADDRESS:

1. SIGNATURE WITNESS 1: 2. SIGNATURE WITNESS 2: NAME & ADDRESS: NAME & ADDRESS:

INDEMNITY BOND WITH SURETY (Office Assistant) (On Rs.100/-Non Judicial Stamp Paper)

This Indemnity is made and executed at____________________ on this______________ day of ________ 20_____ by Shri/Smt/Kum _________________________________ S/o;W/o;D/o Shri __________________________ a permanent resident of________________________________ _______________________________hereinafter called “Employee”, the party of the first part,

AND (i)Shri/Smt/Kum ________________________ S/o;W/o;D/o Shri _________________________ a permanent resident of ________________________________________________________& (ii)Shri/Smt/Kum ________________________ S/o;W/o;D/o Shri _________________________ a permanent resident of __________________________________________________________ hereinafter called “Sureties”, the party of the second part, in favour of UttarakhandGramin Bank,having its Head Office at 18, New Road, Dehradun (Uttarakhand)-248001,a body corporate constituted under the Regional Rural Banks Act, 1976 (21 of 1976) and established vide Gazette Notification dated 01.11.2012 issued by the Government of India, Ministry of Finance, Department of Economic Affairs (Banking Division) hereinafter called “Employer Bank”. The terms ‘Employee’, ‘Sureties’ 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 OFFICE ASSISTANT(MULTIPURPOSE) 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 which has been duly signed and accepted by the Employee. WHEREAS one of the terms and conditions of the appointment is the Employee has to serve the Employer Bank viz. Uttarakhand Gramin Bank for a minimum period of ONE year 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 ofONE year. 2. The party of the second part i.e. (i)______________________ & (ii)____________________ agree to stand as Sureties 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 his/her failure to indemnify the Bank, the Sureties shall be jointly and severally liable to pay Rs. 50,000/-(Rupees Fifty Thousand 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/her leading to termination of his/her service as per rules/regulations by the Employer-Bank, he/she shall be liable to pay a sum of Rs.50000/-(Rupees FIFTY THOUSAND only) which the employee and the sureties 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 ONE year, 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. 5. The amount specified above shall constitute a debt owing to the Employer-Bank and shall be recoverable from the Employee and the Sureties jointly and severally. IN WITNESS whereof, the EMPLOYEE & the SURETIES 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 read and understood the contents/terms of this Agreement. SIGNATURE EMPLOYEE: NAME & ADDRESS: Signed and delivered by the Party of the second part i.e. the Sureties having read and understood the contents/terms of the Agreement_____________________________________

SIGNATURE SURETY 1 SIGNATURE SURETY 2:

NAME & ADDRESS: NAME & ADDRESS:

1. SIGNATURE WITNESS 1: 2. SIGNATURE WITNESS 2: NAME & ADDRESS: NAME & ADDRESS:

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