APPLICATION FORMAT FOR EMPANELLMENT AS BUSINESS FACILITATOR/BUSINESS CORRESPONDENT OF NABARD FINANCIAL SERVICES LIMITED, BANGALORE A. Organizational Particulars 1. Name of the NGO/mFI/mFO : 2. Address : 3. Phone & Fax No. with STD code : 4. E-mail address : 5. Website : 6. Constitution (Please Specify) : 7. (Eg: Trust/Society/Co-op Soc/NGO) 8. Details of Registration / Incorporation (enclose copies): Act/s under which registered Date & Place of registration Registration No. Validity Period 9. Main Activities of the Agency : (Enclose a profile of the agency giving particulars of area of operation, Management/Governing body, CEO Organizational structure, staff, projects undertaken, sources of funding, infrastructure 10. Whether Registered under Foreign Contribution (Regulation) Act, 1976(FCRA)? Yes/No. If yes, indicate details of FCRA No. (enclose a copy) 11. Whether Permanent Account Number (PAN) obtained from Competent Authority? Y/N (If yes, enclose a copy) B. Management 1. Names of members of Governing Body/ Board of Trustees/ Board of Directors / Proprietor/ Partners / Authorised signatories / Principal share holders Name Designation Address Occupation Educational qualification & experience Details of association with any other
institution 2. Details of Board meetings held in last three years : Year No. of Board meetings held 2007-08 2008-09 2009-10 Average attendance (%) 3. Profile of Chief Executive Officer : Name Designation Qualification Experience Date of appointment Details of association with any other institution C. Staffing pattern 1. Please give details of organizational structure/profile (Please attach) 2. Staff details (give for last three years) : Year Office Staff 2007-08 2008-09 2009-10 Supervisory Staff Field Staff Total Staff D. Details of infrastructure available for the activity Type of infrastructure Address/ Description Remarks Head Office Field Offices Vehicles Computers Staff mobility Training facilities Any other (specify)
E. INCOME, EXPENDITURE for past 3 years S No Year Total Income Total Expenditure 1 2007-08 2 2008-09 3 2009-10 Excess of income over expenditure F. Particulars of SHGs formed and credit linked S No Year No of SHGs formed No of SHGs savings Linked Amount in Rs. lakh No of SHGs Amount of credit bank loan Linked G. If acting as MFI date of commencement of MFI activity: H. No of offices I. Area of operation (specify Block/Taluk/District) J. Amount of loan given by MFI No of groups Amount of loans sanctioned (Rs. lakh) K. Amount of loan outstanding as on No of groups Amount of loans outstanding (Rs. lakh) L. Recovery % as % of demand M. Portfolio at Risk (above 30 days) No of groups Amount of PAR (Rs. lakh)
N. Credit Rating of MFI, if any Name of Credit Rating Agency groups Rating Awarded Year of rating O. Details of experience as Business Correspondent/ Business Facilitator P. Date & Reference of resolution passed by the governing body for applying for empanelment as Business Correspondent / Business Facilitator of NABFINS (enclose a copy) Q. Area/ Villages proposed to be covered R. Details of services / activities proposed to be rendered to NABFINS S. Particulars of authorized signatories S. No Name Father s name Design ation Age (years) Qualif icatio n Experie nce (Years) Languag es known Address Contact No. T. Details of Bank Accounts S. Name of the Bank & Branch Account No. IFSC Code 1 2 3
U. Undertaking We understand that our offer under this application will be for acting as a Business Facilitator/Business Correspondent for the limited purposes of such services as decided by NABARD Financial Services Limited and if NABARD Financial Services Limited engages our services, it will not be an offer by NABFINS for any employment in NABFINS now or at any time in future. The contractual arrangements are as mentioned in the Outsourcing Agreement signed both by us and NABFINS and continuance of our services shall be subject to periodic review by NABFINS. Place: Date : Signature(s) of the authorized signatories List of Enclosures (as applicable) Letter from a respectable person regarding character & integrity of the organization An affidavit stating that no criminal proceedings have been registered / are pending against the organization Copies of Annual Reports, Audited P & L / Balance Sheet and IT returns for last three years certified by the auditor PAN / TAN / FCRA approval (Photocopy) Trust Deed / Registration Deed Profile of the organization For Office Use Photocopies verified against original documents (Signature) Name & Designation of the Officer: Date: