1. APPLICATION FORM
To
The Asst./Dy./General Manager, PLEASE AFFIX
Regional Office YOUR RECENT
PASSPORT SIZE
Vijaya Bank, 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
1. CATEGORY TO WHICH I BELONG: SC: ST: OBC: GEN:
(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 Drawn in favour of Date of DD No. Amount
issuing Bank/Branch Issue
(Application fees should be sent in the form of DD favouring "Vijaya Bank - Recruitment of
Peons- 2011" and payable at Lucknow.) Cash, Money Order, Postal Stamps/postal orders will
not be accepted.

2. 7. INDICATE BY  MARK IN APPROPRIATE BOX:
i) GENDER: MALE FEMALE
YES NO
ii) Are you a widow?
YES NO
iii) a) Are you an Ex-serviceman:
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 HI VH
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
vi) Whether children/family members of those died in 1984 riots:
YES NO
vi) Whether you belong to Minority community: YES NO
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 :
8. EMPLOYMENT EXCHANGE REGISTRATION NUMBER & NAME OF THE
EMPLOYMENT EXCHANGE:__________________________if any.

3. 9. FATHER’S/HUSBAND’S NAME (indicate appropriately):
Mr.
10. NATIONALITY : ____________________
11. PLACE OF BIRTH: Place _______ Dist._________ State________
12. PERMANENT ADDRESS:
Pincode:
13. EDUCATIONAL QUALIFICATION
(From VIII Standard onwards; as on 15.07.2011):
Examination Name of the Institution Month & Year %age of
Passed studied of passing marks
(If space is not sufficient, please attach separate sheet)
14. PARTICULARS OF EXPERIENCE, IF ANY:
Name of the Period of Length of Nature of Remarks
employer & nature of Service Service duties (Reason
activities carried by Years Month performed for leaving
them From To 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

4. 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 Lucknow. I undertake to abide by all the terms and conditions mentioned in the
advertisement given by the Bank.
PLACE: ______________
DATE: _____________ SIGNATURE OF THE APPLICANT