BC&BF/Form /1 STATE BAN K OF INDIA APPLICA TION FORM FOR ENGAGEMENT AS BUSINESS CORRESPONDENT
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1 . BC&BF/Frm /1 STATE BAN K OF INDIA APPLICA TION FORM FOR ENGAGEMENT AS BUSINESS CORRESPONDENT Instructins : Use additinal sheets wherever necessary. Strike ut which ever is nt applicable I : GENERAL INFORMATION Name f the MFI / NGO / Entity (e.g. S 25 Cmpany) Legal Status (Registratin N./ type / FCRA Status & Date f Establishment Name f Chief functinary and Designatin Registered address f the MFI/NGO/ Entity Address fr Crrespndence Telephne Number Fax id Website Address Cntact Persn s Name Phne Number id State PIN CODE
2 II. : GENER AL INFO RMATIO N Missin Visin Objectives Gegraphical areas f activity (Villages, district, blcks, taluk / municipalities and states in India where active) 1
3 III. : SPECIFIC INFORMATION (Names f members / Designatin / Academic Qualificatin / Experience) Gverning Bard: Name Designatin Academic qualificatin Backgrund Details Membership in ther Bards, etc. Executive Bard: Name Designatin Academic qualificatin Backgrund Details Membership in ther Bards, etc. Advisry Bard: Name Designatin Academic qualificatin Backgrund Details Membership in ther Bards, etc. 2
4 III. : INFORMATION ABOUT MICROFINANCE PORTFOLIO Since when are yu ffering micrfinance services? Micrfinance (Qualitative) What is / are the lending type (s) yu use Number f branches delivering micrfinance Services Individual Lending Grup Lending Grup Assisted Individual lending Mutual Credit Guarantee Jint Liability Grups Self Help Grups Others (please specify) Number f staff engaged in micrfinance Services N. f Field staff engaged in micrfinance Client Prfile (as f end f December 2006) Number f active clients Gegraphical distributin f clients Urban Semi Urban Rural 3
5 Percentage f wmen clients Number f brrwers Number f active brrwers Average Lan Size Please specify the percentages f the main enterprises fr which the beneficiaries take lans Micrfinance Prducts and Services (as f end f December 2006) Please give details abut the varius types f financial prducts and services yu prvide Savings Prducts (please mentin all the prducts under this categry like saving depsits, recurring depsits, fixed depsits, etc.) Lan Prducts (please mentin varius type f lans that yu prvide under what categry e.g. medical lan under Health) 4
6 Insurance Prducts (Please give the names f Insurance Cmpanies whse prducts yu ffer) Any ther financial prducts r services that yu presently ffer Perfrmance Prfile (as f end f December 2006) Cumulative Amunt f Lans Disbursed (in Lakhs INR) Cumulative Number f Lans Disbursed Amunt f Lan Disbursed in last 12 mnths (in Lakhs INR) Amunt f Lan Outstanding (in Lakhs INR) Number f Lans Outstanding Average Interest rate n Lans (Please indicate the flat rate) NPA % Grants (Amunt and %) Debt (Amunts and %) Internal Funds (Amunts and %) Surce f Funds Fr each f the abve, please give the names f the Agency/Bank/Financial Institutins Please Nte: This infrmatin shuld be accmpanied w ith yur and Audited Financial Statement. Please feel free t prvide any additinal infrmatin r dcument in supprt f the infrmatin given belw. 5
7 II. : ORGANIZATIONAL PROCESSES Please tick any ne Prcess definitin is Review f prcesses is D yu have prcess manuals maintained fr critical prcesses? (thse prcesses essential fr achieving the cre business / gals) Are these prcess manuals understd and implemented by the staff cncerned (Tick One) Hw d yu educate yur cncerned staff members n the crrect prcesses t be fllwed? D yu have a well defined Management Infrmatin System (MIS) If the answer t the abve is Yes, is yur MIS manual r cmputerized? Mentin any best practice develped and implemented by yu fr micrfinance practice (Use Additinal Sheets if required) D yu have the capacity t handle cash management fr the day-t-day peratins? If s, please give details f hw yu will d this? Dne Verbally Dcumented (enclsed cpy) Nt Defined Nt understd Dne Verbally Dcumented Nt Reviewed Yes N Nt Applicable Nt understd Always Never Nt Applicable Handuts Training sessins Presentatins They are put available at the website They are put available at the library / files Center They are nt disseminated Others Yes N Nt Sure Nte Applicable Manual Cmputerized Nt Sure 6
8 VI: OTHERS 0. D yu wrk with any ther Cmpetitr Bank? If s, nature f wrk undertaken 0. Are yu partially / fully cntrlled by any ne wh is any fficer / Directr f SBI r related t any fficer / Directr f SBI 7
9 VII. : ORGANISATIONAL STRUCTURE : Please use this space t add yur Organisatinal Structure Chart 8
10 VIII. If yu wuld like t add any ther infrmatin abut yur activities. Please use this space. 9
11 IX. SWORN STATEMENT BY THE NOMINEE I, the undersigned, being the persn respnsible in applicant entity fr the actin, certify that: (i) (ii) The infrmatin given in this nminatin frm is true and crrect t the best f my knwledge ; and The entity des nt fall under anyne f the undernted categries: a) Is bankrupt r is being wund up, is having its affairs administered by the curts, has entered int an arrangement with creditrs, has suspended business activities, is the subject f prceedings cncerning thse matters, r is in any situatin arising frm a similar prcedure prvided fr in natinal legislatin r regulatins; b) Has been cnvicted f an ffence cncerning prfessinal cnduct by a judgment which has the frce f res judicata (i.e., against which n appeal is pssible); c) Is guilty f grave prfessinal miscnduct prven by any means which the Award Partners and Jury can justify; d) Has nt fulfilled bligatins relating t the payment f scial security cntributins r the payment f taxes in accrdance with the legal prvisin f India; e) has been the subject f a judgment w hich has the frce f res judicata fr fraud, crruptin, invlvement in a criminal rganizatin r any ther illegal activity; I am fully aware that any false declaratin will lead t the exclusin f the entity frm the selectin prcess. Name : Psitin : Signature : Date and Place : Seal 10
12 CHECKLIST FOR ENCLOSURES 1. Audited Financial Statements fr the year ending March, 2005 and Annual Reprt fr the last 2 years (if printed). 3. One cpy f phtgraph (passprt size) f the rganizatin s Chief Executive. 4. Cpies f the certificate f registratin authrized by an independent authrity. 5. Rating reprt (if rating has been dne). 11
13 BC&BF/Frm/1A APPLICATION FORM FOR BUSINESS FACILITATORS (ENTITIES) Sr. N. Pariculars (additinal sheets may be attached, where necessary) LOCATIO N APPLIED FO R : 1 Name f the Organizatin 2 Address fr Crrespndence ( , phne, mbile n.) 3 Name f the CEO/ Secretary / President etc. (bi-data with phtgraph enclsed) 4 Date f Establishment & Registratin N., if applicable 5 Rating awarded by an external agency, if any (reprt enclsed) 6 Are yu an eligible entity as per RBI Guidelines? (If yes, mentin relevant clause) 7 N. f years f existence 8 Activities undertaken during 2/3 years 9 Banking with : Bank Name Since Accunt n. 10 Area cvered (Talukas / Mandals / Blcks / Districts) 11 Names f the Branches, if any (with their addresses) 12 Name f persns / entities knwn t the bank as references (Addresses, Cntact ns.) i. ii. 12
14 13 If acting as Business Crrespndent / Facilitatr fr any ther rganizatin, details theref 14 Details f Technlgy Tie-up (fr BC nly) 15 Ntable achievements, if any 16 Any ther infrmatin 17 Enclsures : i.audited Financial Statements fr the last 3 years ii.brief resume f the rganizatin / cmpany iii.bi-data f CEO iv. Registratin / Certificate f Incrpratin v. Rating Agency s Certificate / Reprt 13
15 BC&BF/Frm/2 STATE BANK OF INDIA APPLICATION FORM FOR BUSINESS FACILITATORS (INDIVIDUALS) 1. Lcatin (Village / Twn) - Lcatin - District - State - PIN 2. Name (IN BLOCK LETTERS) 3. Father s / Husband s Name 4. Date f Birth 5. Gender (Please Tick) - Male Female 6. Marital Status (Please Tick) - Married Unmarried 7. Educatin (Please Tick) - Belw Class X Class X Class XII - Graduate Pst Graduate and abve 8. Permanent Address - P.O. Tehsil - District - State Pin : 9. Cmmunicatin Address - P.O. Tehsil - District - State Pin : 10. Telephne N. (with STD Cde) - Residence - Office - Mbile 11. ID, if any Currently Banking with (Bank) Bank Accunt Number, if any Cheque Facility (Please Tick) - Available Nt Available 15. *Prf f Name (Please Tick) - Driving License PAN Card (Anyne) - Vter s ID Card Passprt 16. *Prf f address (Please Tick) - Electricity Bill (Latest) NSC (Cpy) Telephne Bill (Latest) LIC Plicy (Cpy) Letter frm landlrd Gas Cnnectin 14
16 17. Present Business / Occupatin, if any 18. Cmputer Literacy : Yes N 19. If yes, nature f qualificatin : 20. If yu already wn a business r are wrking yur revenue / incme per mnth is 21. D yu have any experience in selling financial prducts? If yes, give details. Less than Rs.1000 Rs Rs.2500 Rs Rs.4000 Rs Rs.6000 Mre than Rs Languages knwn (say fluent / nt s fluent) English Hindi Reginal Language (specify) Any ther (specify) 23. N. f years f stay in the twn / village Read Write Speak 24. D yu have any plice recrds? If yes, give details. 25. Names, address and ccupatin : 1) f tw peple t whm reference can be made. 2) I certify that the abve infrmatin is true t the best f my knwledge and belief. Signature f the applicant 15
17 Address & ID Prf * * May be btained frm Sarpanch /Mukhiya /Gazatted Gv t. Servant / Pst Master / Tahsildar / Plice Inspectr / Gv t. Teacher This is t certify that Mr. / Ms. / Mrs. has been a resident f (Cmplete Address) fr. years and hlds a gd character in the area. His phtgraph is herewith attested and I cnfirm the same. His date f birth is (Signature) Name:... Address:... Designatin (with seal) : References 1) I hereby certify that has been a resident f... Village / twn f... district in State f perid f.. years and has been knwn t me fr perid f.. years. (Signature) Name f Referee Address:.. Designatin / Title : 2) I hereby certify that has been a resident f... Village / twn f... district in State f perid f.. years and has been knwn t me fr perid f.. years. (Signature) Name f Referee Address:.. Designatin / Title : 16
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