Bihar RajyaJEEViKA NIDHI Credit Coopertaive Union Limited,
Patna (JEEViKA NIDHI)
Application Form
(To be filled by the Officer, JEEViKA NIDHI/JEEViKA)
Registration No
(To be filled by the candidate in CAPITAL LETTERS)
1. Post Applying For* (i) Please paste
onepassport-size photo
3x4” and
2. Date of Walk-in-Interview
(ii) Attach one
3. Name of the Candidate colorphotowith the
(As in 10th Certificate) * application
form )
Personal Details
4. Category
(UR/EWS/MBC/BC/EBC/SC/ST/BC
(F))
4a. Do you claim for reservation 4b. If Yes, 4c. Xerox Copy submitted
Submission of Non-Creamy
(Yes/No) (Yes/No)
Layer Certificate (Yes/No)
5. Do you claim for reservation
against persons with disability (PWD)
5a. If Yes, 5b. Xerox Copy
Percentage of disability submitted (Yes/No)
(Yes/No)
6. Sex (Male/Female)
7. Name of Father (As in 10th
Certificate) /Husband
8. Name of Mother
9. Date of Birth (DD/MM/YYYY)
Years
9a. Age (As on 01.04.2024) Months Day
Xerox copy
10. Resident of Bihar (Yes/No) attached
(Yes/No)
Page 1 of 4
10.a. If Yes
(Please mention Domicile Certificate
No. & Date issued by CO/SDO/DM)
10.b. If Yes
(Caste Certificate issued by
SDO/DM)
11. Proof of Identification
(Voter ID/ Aadhar Card/
DL /PAN/Passport or any
other proof issued by
Govt.)
12. PAN No (If available)
13. Email Id
14. Mobile No
15. Permanent Address:-
16. Correspondence Address: -
17. Details of Academic & Professional Qualification
Marks
Qualification Name of Board/ Specialization Passing Date Xerox Copy
University/Institution (If Any) (DD-MM-YY) Full Marks Submitted
Marks Secured %
(Yes/No)
Page 2 of 4
18. Details of work Experience (If any)
To Total Xerox Copy
experience in Submitted
S.N. Name of Employer Designation From (Yes/No)
month
19. For Reference Check (Please provide the following details)
1) Name & 2) Name &
Designation : Designation :
Mobile No.: Mobile No.:
Email ID: Email ID:
20. Declaration by the candidate
I hereby declare that all the above information and documents submitted are correct. I understand that in the event of any information
being found suppressed/false or incorrect or any ineligibility being detected before or after joining, my Candidature/ appointment is
liable to be cancelled and legal action may be taken against me.
Name & Signature of the candidate
Date:
Page 3 of 4
21. ( To be filled by Document Verification Team, BRLPS)
19.a Remarks on Academic & Professional Qualification 19.b. Remarks on Working Experience (if any)
22. Status of Document Verification
(To be filled by Document Verification Team)
Qualified/Conditionally Cleared/Disqualified:
Any other remarks:
Name & Signature of Document Verification Team
Date
Page 4 of 4
