3762

pwafd Hkkjrh; thou chek fuxe ftls vkxs

^^fuxe** lEcksf/kr fd;k x;k gSA }kjk Jh
------------------------------------------------------------------------------
--------------------- ds thou ij
fcfer O;fDr dk uke
fnukad --------------------------------- dks :0
--------------------------------dh chek ikfylh
la[;k------------------------------------------------------------------------
-------------------
tkjh dh xbZ Fkh vkSj pwafd ¼chesnkj dk uke½
--------------------------------------------------------- dk
lR;fu"BkiwoZd fuf'pr :i ls ;g dguk gS fd mDr ikfylh la[;k
----------------------------------- tks ¼[kksus dk laf{kIr fooj.k½
--------------------------------------------------- dkj.k gks xbZ
Fkh@Fkh] vkSj flok; ,sls -------------------------------------------
leuqns'ku ds ftldh lwpuk fuxe dks igys gh nh tk pqdh gS
u rks mldk leuqns'ku fd;k x;k Fkk] u mls cU/kd jD[kk x;k
Fkk vkSj u mls fdlh vU; izdkj ls O;og`r fd;k Fkk vkSj ;fn
ewy ikfylh@ikfyfl;ka ckn esa fey tkrh gS@gSa rks ;g
izfr:i ikfylh@ikfyfl;ka fuxe dks okil dj nsus ds fy, cpuc)
gksrs gSaA vkSj pwafd mDr fuxe ¼cheknkj dk uke½
---------------------------------------------------------------- dks mDr
ikfylh la[;k -----------------------------------------------------dh
izfr:i ikfylh tkjh djus dks bl ij lger gks x;k gS fd loZJh
---------------------------------------------------------
¼cheknkj] izfrHkw] leuqns'krh
tu½
fuxe ds lkFk vkxs fn;s vuqlkj izfrKkc) gks tk;saxsA vr
% ;g nLrkost bl ckr dk lk{kh gS fd mijksDr bdjkjukes ds
vuqlkj rFkk bl ckr dks /;ku esa j[kdj fd fuxe nLrkost ds
fdz;kfUor fd;s tkus ij Jh
------------------------------------------------------------------------------
dks izfr:i ikfylh tkjh dj nsxkA loZJh
----------------------------------------------------------------------------
¼cheknkj] izfrHkw] leuqns'krh½
fuxe mlds mRrjkf/kdkjh ,oa iz;uqns'kfr;ksa ds lkFk
izfrKkc) gksrs gSa fd os
------------------------------------------------------------------------------
--------------------------------------------------------------------Lo;a
¼cheknkj] izfrHkw] leuqns'kfr½

rFkk lnSo lHkh izdkj dh dk;Zokfg;ksa eqdneksa] O;;

nkoksa ,oa fdlh Hkh izdkj dh ekax ls cpk;saxs] gkfujfgr
j[ksaxs vkSj
 ¼2½
ml {kfr dh iwfrZ djsaxs tks fuxe mlds
mRrjkf/kdkfj;ksa ,oa leuqnsss'kfr;ksa ds fo:) fdUgh
O;fDr@O;fDr;ksa ds }kjk ewy ikfylh la[;k
-------------------------------------------ds nLrkost ij dCtk gksus
ds dkj.k vFkok mlesa fdlh mYys[k }kjk gdnkj gksus ds
dkj.k mRiUu gksaxsA
mijksDr dh lk{kh esa mDr ¼cheknkj]
leuqns'krh½ o izfrHkw ds uke
------------------------------------------------------------------------------
------------------------------------------------------------------------------
------------------------------------------------------------------------------
------------------------------------------------------------------------------
us vkt LFkku ----------------------------------------------- esa
fnukad ---------------------------
ekg------------------------------------------------
-------------------------------------------------- 200-------------------
dks gLrk{kj fd;sA
vUr% cf.kZr O;fDr;ksa }kjk gLrk{kfjr o izLrqr
1& ---------------------------------------------- 1
-------------------------------------------------
¼cheknkj dk uke½ ¼cheknkj
ds gLrk{kj½
2& -------------------------------------------------
2& ----------------------------------------------------
¼leuqns'khrh dk uke½
¼leuqns'kfr ds gLrk{kj½
-------------------------------------------------
3& -------------------------------------------------
¼izfrHkw dk uke½ ¼izfrHkw ls
gLrk{kj½
O;olk;
-----------------------------------------------
irk
-----------------------------------------------------
bu lkf{k;ksa dh mifLFkfr esa %
1& lk{kh %
gLrk{kj ------------------------------------------
iwjk uke ----------------------------------------
O;olk; -----------------------------------------
irk ------------------------------------------------
2& lk{kh %
gLrk{kj ------------------------------------------
iwjk uke ----------------------------------------
O;olk; -----------------------------------------
irk ------------------------------------------------
3& lk{kh %
gLrk{kj ------------------------------------------
iwjk uke ----------------------------------------
O;olk; -----------------------------------------
irk ------------------------------------------------
 3815

pwafd Hkkjrh; thou chek fuxe ftldh LFkkiuk

1956 ds 31 os Hkkjrh; thou chek fuxe vf/kfu;e ds }
kjk gqbZ gS ¼ rFkk ftls vkxs ^^fuxe** dgk x;k gS
½ ds }kjk
------------------------------------------------------------------------
------------------------------------------------------------------------
-------------------------------------------------------------------¼c
hesnkj dk
uke½----------------------------------------------------------------
------------------------------------------------------------------------
-------------- ds thou ij ikfylh la0
-------------------------------------:i;s----------------------------
fnukad ----------------------------- dks tkjh dh x;h Fkh
vkSj pwafd mijksDr ikfylh la0-------------------------
vH;i.kZ nLrkost fnukad tks
--------------------------------------------ds ikl Fkh @Fkk
[kks x;h @x;k gS vFkok xqe gks xbZ @x;k gS vkSj
pwafd mDr fuxe ikfylh dk ewY; :i;s
------------------------------------------------------------------------
------------------------------------------------------------------------
--------------------------------------------------------------------Jh
------------------------------------------------------------------------
------------------------------------------------------------------------
------------------------------------------------------------------------
---------izkIrdrkZ]izkIrdrkZvksa dk@ds uke
dks Hkqxrku djus dks bl vk/kkj ij lger gks x;k gS fd
loZJh
------------------------------------------------------------------------
------------------------------------------------------------------------
---------------------------------------
¼ikfylh/kkjd ,oe~ izfrHkw½
fuxe ds lkFk vkxs fy[ks vuqlkj izfrKkc) gks tk;sxsa
vr% vc ;g nLrkost bl ckr dk lk{kh gS fd mijksDr
bdjkjukek ds vuqlkj rFkk bl ckr dks /;ku esa j[kdj fd
fuxe bl nLrkostu ds fdz;kfUor fd;s tkus ij mijksDr Jh
------------------------------------------------------------------------
-----------------------------------------------------------------dks
ikfylh dk ewY; Hkqxrku dj nsxk] ¼ftldh izkfIr½
¼ikfylh /kkjd@dk@ds uke½
,rn~}kjk Lohd`r dh tkrh gS ½ ] mDr
------------------------------------------------------------------------
-----------------------------fuxe] mlds
¼ikfylh /kkjd rFkk izfrHkw½
 ¼2½
mRrjkf/kdkjh ,oe~ vH;fFkZ;ksa ds lkFk izfrKkc)
gksus gS fd og
------------------------------------------------------------------------
------
¼ikfylh /kkjd
rFkk izfrHkw½
Lo;a mlds@ muds mRrjkf/kdkjh] dkfjUns rFkk
iz'kkld fuxe ,oa mlds mRrjkf/kdkjh ,oa vH;fFkZ;ksa
dks le;≤ ij rFkk lnSo lHkh izdkj dh dk;Zokfg;ksa]
eqdneksa] O;; nkoksa ,oa fdlh izdkj dh ekax ls
cpk;sxsa] gkfujfgr j[ksxsa vkSj mldh {kfr dh iwfrZ
djsaxsa tks fuxe mlds mRrjkf/kdkjh ,oa vH;fFkZ;ksa
ds fo:) fdUgha O;fDr] O;fDr;ksa ds }kjk ewy ikfylh
la0
--------------------------------------------------------------------ds
nLrkost ij dCtk gksus ds dkj.k vFkok mlesa mfYyf[kr
ds }kjk gd gksus ds dkj.k mRiUu gksxsa A
mijksDr dh lk{kh esa
mDr------------------------------------------------------------------
-------------------------------us vkt
¼ikfylh /kkjd rFkk izfrHkw½
fnukad
-------------------------------------dks------------------------------
--------------------------------------gLrk{kj fd;s x;sA
 LFkku
fuEufyf[kr lkf{k;ksa dh mifLFkfr esa %&
¼1½--------------------------------------------------------------

¼2½----------------------------------------------------------------
------------
¼ikfylh/kkjd ½ ¼ikfylh/kkjd ½
izzfrHkw -----------------------------------------}kjk
gLrk{kfjr fd;k x;k vkSj lqiwnZ fd;k x;k %
lk{kh% gLrk{kj%
¼1½ lk{kh ds iwjs gLrk{kj ¼1½
---------------------------------------------------------
¼chek/kkjd½
in------------------------------------------------
¼2½ ----------------------------------------------------------
¼chek/kkjd½
irk --------------------------------------------
¼3½ -----------------------------------------------------------
--------------------------------------------
¼izfrHkw½
¼2½ lk{kh ds iwjs gLrk{kj in
-------------------------------------------------------
in ---------------------------------------------
irk -------------------------------------------------------
irk -------------------------------------------
----------------------------------------------------------------
---------------------------------------------
pwWafd----------------------------------------------------cSad
ij--------------------------:0
¼:i;s---------------------------------------------------------------------------------
----------------------------½
dks fnukad--------------------------------dh psd
la0------------------------------Hkkjrh; thou chek fuxe ¼ftls blds ckn
fuxe dgk x;k gS½ }kjk---------------------------ds uke esa tkjh dh
xbZ Fkh vkSj pwWafd mDr psd [kks xbZ gS ;k ykirk gks xbZ gS
vkSj pwWafd fuxe us gekjs fuosnu ij
mDr----------------------------------------------------------------------------------
----------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------
--------------------------------------------------dks mDr [kksbZ vFkok
ykirk psd ds LLFkku ij izfr:i psd tkjh djuk bl vk/kkj ij Lohdkj dj
fy;k gS fd ge vkxs fy[ks vuqlkj {kfriwfrZ vuqcU/k dk;kZfUor dj
nsxsa A vr% vc ;g vfHkys[k bl ckr dk lk{kh gS fd ge
mDr----------------------------------------------------------------------------------
-----------------------------------------
¼psd dh jkf'k ds ewy izkIrdrkZ dk
iwjk uke½
rFkk----------------------------------------------------------------------------------
----------------------------------------------------------------------------------------
----------------,rn~}kjk fuxe] muds mRrjkf/kdkfj;ksa rFkk
vH;fFkZ;ksa ds lkFk izfrKkc) gksrs gSa fd os Lo;a rFkk muds
mRrjkf/kdkjh] dkfjUns rFkk iz'kkld mDr fuxe] mlds mRrjkf/kdkjh
rFkk vH;fFkZ;ksa o fuxe ds lnL;ksa rFkk fuxe ds vf/kdkfj;ksa
rFkk Øe'k% mudh py&vpy lEifRr;ksa dks le;≤ ij rFkk lnSo
lHkh izdkj dh dkjokb;ksa eqdneksa] O;;] nkoksa ,oa fdlh izdkj
dh ekax ls cpk;sxsa vkSj ml gqbZ {kfr dh iwfrZ djsxsa tks
muds fo:) fdUgha O;fDr ;k O;fDr;ksa }kjk [kksbZ ;k ykirk gqbZ
psd ds :i;s ds ckjs esa mRiUu gksxsa A
Jh-------------------------------------------;g Hkh ftEesnkjh ysrs gSa fd
;fn Hkfo"; esa dHkh og [kksbZ ;k ykirk psd fey xbZ rks mls fuxe
dks okil dj nsxsa A
mijksDr dh lk{kh esa mDr----------------------------------
¼psd dh jkf'k ds ewy izkIrdrkZ dk
iwjk uke½
rFkk------------------------------------------------us vkt
fnukad-------------------------------------------------dks
¼izfrHkw dk iwjk uke½
-------------------------------------esa fuEufyf[kr lkf{k;ksa dh mifLFkfr
esa vius gLrk{kj fd;sA
1& lk{kh ds iwjs gLrk{kj psd dh jkf'k ds ewy
izkIrdrkz ds gLrk{kj
in 1&
irk& 2&
2& lk{kh ds iwjs gLrk{kj
in izfrHkw ds gLrk{kj
irk izfrHkw dk in
izfrHkw dk irk
 BANK OF INDIA

SAFE DEPOSIT DEPARTMENT

AZAMGARH BRANCH, AZAMGARH

MEMORANDUM
 BANK OF INDIA (hereinafter called the Bank)

agree to let and______________ __________

__________________________(hereinafter called the

Lessee) agree to Hire subject to conditions endorsed

the Bank's Safe

No.____________________Class_______________for

one/two/three years from this day for a Rent of

Rs.__________________(the receipt whereof is hereby

acknowledge by the Bank) payable in advance. The

said lease to continue (at the same

yearly/Biennial/Trinnial Rent, payable in advance and

subject to the same conditions) untill such Lease

shall be determined in accordance with the

conditions endorsed thereon.

While Bank will exercise all necessary

preesutions as it may in its absolute discretion deem

fit. It does not accept any liabilities form any

damage what soever sustained in the items

deposited with it. Accordingly Leassee may in their

own interest ensure any item or value deposited in

the safe deposit locker with the Bank.

Leasee can modify that frequency of

payment of rent from annually to

biennially/Trainnially or vice verse by intimating the

Lessor before expiry of the existing lease period.

The content of the Safe Deposit Locker will

be allowed to be taken possession of by Nominee of

the Leasee in the event of death of the Lessee

provided that the Lessee had appointed the Nominee

by following the procedure prescribed under the

Banking Companies (Nomination) Rules, 1985.

FOR BANK OF INDIA

CUSTODIAN

LESSEE___________________

_______________________

TERMS & CONDITIONS FOR THE INSTALLATION

MAINTENANCE AND OPERATION OF

PAYPHONES
1. Name________________________________(here
in after called licensece) will install and operate STD
PCO at_____________________
__________________________name of
place/city_______________at locations to be indicated
by the licensee.
2. The licensee will indicate the telephone
exchange areas in which he will like to establish the
above payphones.
3. The licensee will be provided a direct
exchange line with S.T.D. & I.S.D. facility for pay
Phone (permitting local and S.T.D. calls for which no
rent of installation charges will be lovied).
4. The licensee will provide a suitable
Department of Telecommun- ication's type approved
telephone instrument accommodation and the booth
at he own cost. The charge indicator would not be
programmable locally.
5. Other that the departmentally approved call
loggers/P.C.O. Monitor the licencee will not be
permitted to use any other Instrument/attachment
koither in parallel with or in place of the above.
6. Normal Maintenance, repair and servicing
facilities to the direct exchange lines provided to
other subseribrs will be extended by the Department
of Telecom to the licensee. The licensee will follow the
normal reporting Proceduee.
7. The Licence will be permitted to charge to
call charges as prescribed by the Department of
Telecom from time to time, per call unit, from she
public for the calls made from the S.T.D., P.C.O.'s and
retain the commission as prescribed by the
Department from time to time.
8. The licensee will pay a refundable non-
interest bearing security deposit as fixed by the
department. The Department will have the right to
revise the qantum of the security deposit from time
to time. The refund of the security deposit would be
made when the S.T.D., P.C.O. is closed after payment
of the outstanding bills.
9. The licensee will procure, install; maintain
and operate at his own cost the payphones at the
agreed locations. The licensee shall be responsible
for payment of departmental bill/dues as per
frequency specified by the Department. All such
payment of bill be made by the due date as specified
there in and in the case of non-payment of the same,
the payphone)s) will be liable to be disconnected
straight forth.
10. The licensee will make payments as per the
matered call recorded in 0the exchange.
11. The leicusce shall collected from the callers
the prescribed charges for the call that the rates
prescribed from time to time kby the Government. He
shall also take adequate stope to see that payphones
are not misused and rates higher than the prescribed
by the Government are not charged from the public.
The Department will have in Talibberty in
revising/modifying the rates of commission payable
to the licensee from time to time, call charges
leviable rates of minimum guarantee, security
deposit; etc.
12. The license will fully cooperate with the
Department of Telecom to investigate any complaint
from the public.
13. The Department will have the right to
inspect so as to insure that the payphone aee
working as per the prescribed conditions for the
licensee as also rigarding the rates belong charged
from the public.

14. The licensee will not be entitled to any

rebate on account for wrong calls or allege excess
metering. No free call will be permitted.
15. The payphone will allow local, national and
international truck dialling facilities. All emergency
service number will be permitted fress of charge by
the licensee.
16. No opperator assisted trunk call will be
permitted on these payphone.
17. The payphone shall be kept open for a
minimum number of hours (6 A.M. to 10 P.M.) as
prescribed by Department of Telecommunications.
18. The licensee shall also have the right to
replace the payphones with advanced, improved and
modified versions as and when they may be
inttoduced after due approval from the Department of
Telecommunications.
19. The licensee shall be free to advertise the
existence of the facility of the payphones.
20. The licensee cad terminate this arrangement
by giving notice of three months to the Department
the Department of Telecommunications will have the
right to terminate the licence in the event of breach
of any of the provisions in the licence by giving notice
konly one week to the licence. Notice shall be deemd
to have been duly given if sent to the premises of the
licencee by registered post.
21. All the operations of the licensee or his
employee with respect to the porovisions,
maintenance and operations of payphone will be
subject to the provisions of the Indian Telegraph Act
and Rules.
22. The licensee shell not divulge or make
known to any persons other than theGovernment any
of the matters relating to the business of the
Government or any business of the callers which may
come to the license'c knowledge.

23. The liensee will ensure that no other

Telephone is working in the premise of pay phone.
24. Any dispute arising rigarding the provision of
this license shall settled through arbitrations as
provided under section 7(b) of the Indian Telegraph
Act.
25. It will be responsibility of the licencee to
collect and pay the Telephone Bills in time Failing
which pay phone will be disconnected without any
prior notice.
26. The licensee will have abido by the policy of
the Department as revised/modified from time to
time without any prior notice to licensee in respect of
all matters including the amount of security deposit
minimum guarantee amount call charges to be levied
commission payable to the licensee.
Signature of Licensee
 Photo Passport
size
3 Nos.

Date & Place: Sigues by

Telecom
Authority
Date and Place
ICENCE GRANTED UNDER INDIAN TELEGRAPH
ACT 1985
In excercise of the power of the Central
Government under sub section 2 of section 4 of the Indian
Telegraph Act, delegated to the Telegraph Autority by GSR.
806, Gazettee of India, Part_II Section 3 (i) dated 24th
August, 1995, the General Manager Telephones/
Telecommunications.......................................(The Telegraph
Authority) hereby grants a licence to
name ................................................ to install, maintain
and operate .......
................................................................... within the
jarisdication of ...............................
(Name of area) .................................
2. The licence is granted for period of three years
from ...............................................
after which the licencess has to get it renwed
from the Telegraph Authority.
3. The Telegraph Authority may at any time revok the
licence on the breach of any of the terms and
conditions therein contained or on defualt of payment of
my contribution payable there under as for e.g. misuse
payphone. refusing use of payphone to public,
unauthorised charging from public, levying of any
surecharge or extra charges or in default of payment of
any dues/ bills payable there under etc.or any other
conditions Laid down by the Department from time to
time.
4. Terme and condition of the licence are given in the
Annexure to this licence.
5. The Telegraph Authority reserves the right to modify at
any time the terms and conditions of the licence if the
Telegraph Authority is satisfied that is necessary or
expedient to do so in the inteest to the general public
or for proper operation of
STD. PCOs
6. The licence shall be governed by the provisions of the
Indian Telegraph Act. 185 as modified from time to time
and in the case of a conflit between the provisions to
the Indian Telegraph Act and those in the schedules of
this licence,. the provision of the Indian Telegraph Act and
these in the schedules of this licence the provisions of the
Indian Telegraph Act shall preval.

( ) ATTESTED
TDM
Franchisee PHOTO
Mau
Name & Address PASS POSRT SIZE
The Sr. Divisional Manager,
Life Insurance
Corporation of India,
.................................... Divisional Office,
.................................................................

Dear Sir,
In consideration of your having granted
and agreed to grant me advances from time to
time against the commission that I may be entitled
to in respect of the business complete by me for the
purpose laid down in the Scheme of advances to
grant formulated by corporation, and as it may be
amended by the Corporation from time to time. I
hereby agent to pay the interest on each of the
advances from the date thereon at the rate which is
in to from time to time under the Scheme and I
hereby irrevocably direct authorise and employee
you to recover the amounts of all such advances
and interest as may be outstanding and time to
time in full from the commission accuring due to me
from time to time.

I also hereby agree that in case I fail to

submit whithin three months from the date of grant
of any advance, the receipts, voucher etc. that may
be relevant in respect of each advance in proof of
having utilised the advance for the purpose for
which it was granted, the outstanding advance shall
be recoverable from me in twelve monthly
instalments together with interest 13½% per
annum or at such enhanced rate as may be in force
at the relevant time under scheme.

And I hereby agree the undertake to make

all such application as may be necessary from time
to time to renew my licence to work as an Insurance
Agent and to obtain the requi licence from time to
time as may be necessary to enable me to receive
and take such commission and not to d any act or
thing whereby any such licence may revoked of
where I may be prevented in law in any way from
recovering and receiving such commission in future

And I hereby further agree that on

termination of my agency either by death or any
cause whatsoever any outstanding balance of the
advance of the advance made by the corporation
with interest therein will be a first charge on any
moneys payable by the Corporation to me or to me
he assignees or nomenees in respect or renewal
commission or any account whatsoever.

Date at _______________ this _______________

day of ___________ 200

Yours faithfully,
 Witness: Signature
________________
Name :___________________
Name :___________________
Designation :______________
Agency Code No. ___________
Address :_________________

Form No. 3264

LIFE INSURANCE CORPORATION OF INDIA
FORM OF NOMINATION

I, ..................................................................
...... the Assured under the within Policy hereby
nominate under Section 39 of the Insurance Act
1938 my (relationship) ........................................
named ............................................
aged ........................ years and whose address
is ................................................ as the person to
whom the mineys secured under this policy shall be
paid in the event of my death.

Signed at ....................................
this .................. day
of ....................20.......................
Witness :
...................................................... ............
...................................................
(Signature in English) (Signature
of Life Assured)

Full Name ........................................ "Certified

that the contents of
the .......................................................... above
nomination have been explained by me to the
affixed his signature/thumb
impression thereto in my
presence, after thoroughly understanding the
same."

........................................
...............................
(Signature of
Witness)

_________________
 DECLARATION OF AGE

(To be completed in the presence of a magistrate or

a Notary or any other Officer empowered to
administer oaths in non court matters by the person
whose age is to be proved)

I..........................................................son
of .....................................................by
occupation .................................................................
.........residing
at ................................................................... do
hereby solemnly affirm and declare that to the best
of my knowledge and belief, I was born
at ......................................on
the .....................................day of ............................
one thousand
...........................................hundred ..........................
...........and am of ....................years of age.

I make this solemn declaration solemnly and

sincerely beleiving the same to be true and
knowing that on the faith hereof the LIFE
INSURANCE CORPORATION OF INDIA will admit my
age in their records and that this declaration would
be receivable as evidence in any future litigation
that may take place in connection with the policy
and that to the best of my knowledge and belief no
other reliable documentary evidence is available in
proof of my age.

.................................
...................................
Sifgnature of
(Prposer/Life Assured)

Decalred before me
at .................................................and certified that
the declaration has been read over to and
understood by the declarant
this ..................................... day
of ...........................20.....................

.................................
..................................
(Magistrate or a
Notary or any officer
empowered to administer oaths
in non court
matters)
The Sr. Divisional Manager,
Life Insurance of India,
.................................... Divisional Office,
.................................................................

Dear Sir,
In consideration of our having granted and
agreed to grant me advances from time to time
against the commission that I may be entitled to in
respect of the business complete by me for the
purpose laid down in the Scheme of advances to
agents formulated by corporation, and as it may be
amended by the Corporation from time to time. I
hereby agent to pay the interest on each of the
advances from the date thereon at the rate which is
in to from time to time under the Scheme and I
hereby irrevocably direct authorise and employee
you to recover the amounts of all such advances
and interest as may be outstanding and time to
time in full from the commission accuring due to me
from time to time.
I also hereby agree that in case I fail to
submit whithin three months from the date of grant
of any advance, the receipts, voucher etc. that may
be relevant in respect of each advance in proof of
having utilised the advance for the purpose for
which it was granted, the outstanding advance shall
be recoverable from me in twelve monthly
instalments together with interest 13½% per
annum or at such enhanced rate as may be in force
at the relevant time under scheme.
And I hereby agree the undertake to make
all such application as may be necessary from time
to time to renew my licence to work as an Insurance
Agent and to obtain the requi licence from time to
time as may be necessary to enable me to receive
and take such commission and not to d any act or
thing whereby any such licence may revoked of
where I may be prevented in law in any way from
recovering and receiving such commission in future
And I hereby further agree that on
termination of my agency either by death or any
cau whatsoever any outstanding balance of the
advance of the advance made by the corporation
with interest therein will be a first charge on any
moneys payable by the Corporation to me or to me
he assignees or nomenees in respect or renewal
commission or any account whatsoever.

Date at _______________ this _______________

day of ___________ 200

Yours
faithdully,
Witness: Signature
________________
Name:___________________
Name :___________________
Designation:______________
Agency Code No. __________
Address:_________________
_________________
 FORM NO. 3815 A
LIFE INSURANCE CORPORATION OF INDIA
................Divisional Office
.............. Branch Office
FROM OF LETTER OF INDEMNITY
 (Applicable where the net claim amount payable
exceeds Rs. 1,000/-
but does not exceed Rs. 5,000/-)
To,
The Sr/Divisional/Branch Manager,
Life Insurance Corporation of India.
.......................................................
.......................................................
Dear Sir,
WHEREAS a policy of Insurance
Numbered ................................ for
Rs........................................... was granted
on ............................... (Date of Policy)
by............................ . (Name of the erstwhile
Insurer)/Life Insurance Corporation of India on the
life of.............................................................. (Name
of the life Assured). misplaced and not traceable in
spite of diligent search,
AND WHEREAS upon my/our representation
that the said Policy document/Deed of Assignment
has not been transferred or dealt with by me/us in
any manner,
AND WHEREAS on my/our undertaking that if
the said Policy/Deed of Assignment is found it shall
be returned to you for cancellation, you have
agreed at my/our request to pay me/us the value of
the said Policy viz. Rs. ......................
(Rupees........................... ..........................................
.) only, on my/our giving you this letter of
Indemnity.
NOW in consideration of the promises I/We for
myself/ourselves, my/our heirs, executors and
administrators agree and undertake from time to
time and at times hereafter to indemnify and keep
you and the Life Insurance Corporation of India
harmless and indemnified from and against all
claims, demands, actions, liabilities and expenses
which may be made or taken against or incurred by
you or the said Life Insurance Corporation of India
by reason of such payment of the values of the
Policy without production of the said Policy
document/Deed of Assignment.

Dated at .......................................
this....................................... day
of .......................................... 20........

Yours
Faithfully
WITNESSES :
1. Signature :........................ 1.
Full Name:........................ 2.
Occupation:...................... 3.
Address:..................... 4.

2. Signature :........................
Full Name:........................
Occupation:......................
(SIGN
ATURE)

Appendix 1/36 for the existing Appendix 1/36

Substitute for the following
Appendix 1/36
Rule 101, Serial No. 25
CONCESSION CERTIFICATE
 Form for the permission of
grant of Railway concession to
orthopaedically/ paraplrgic
person/patient to be signed by
the Govt. Doctor.

This is to certify that

Km./Shri/Smt. ........................................................
Whose particulars are furnished below, is a
bonafide orthopaedically/paraplegic person/patient
and CANNOT TRAVEL WITHOUT THE ASSISTANCE OF
AN ESCORT.
Particulars of the othopaedically
Handicapped/paraplegic person/petient :

(a)

Address :.....................................................................
...................................................................
(b) Father's/Husband's
name :........................................................................
..................................
(c)

Age : ..........................................................................
.......................................................... (d)

Sex .............................................................................
...............................................................
(e) Nature of Handicap : (To be written by Doctor,
whether the disability is Temporary or

permanent) :...............................................................
....................................................................
(f) Causes of loss of functional
capacity :....................................................................
..................
(g) Signature or Thumb impression of
orthopaedically handicapped/paraplegic person/

patient:.......................................................................
..................................................................
 ____________
__________
(Signature
of Govt. Doctor)
Place :____________
Date :_____________

Clear Seal Government

Seal containing full name
Hospital/Clinic &
Regn. No. of the Doctor
 Strike out where not applicable.
NOTE :
(1) The certificate should be issued only to those
orthopaedically handicapped/paraplegic
person/patient WHO CANNOT TRAVEL WITHOUT
THE ASSISTANCE OF AN ESCORT. The photo must
be signed and stamped in such a way that Doctor's
Signature and Stamp appears partly on the photo
and partly on the certificate.
(2) In the case of temporary disability, the
certificate will be valid for fice years from the date
of issue. In the case of permanent disability, the
certificate will remain valid for (1) Five years, in
case of persons upto the age 25 years (2) Ten
years, in case of persons in the age group of 26
to 35 years and (3) in the case of persons above the
age of 35 years, the certificate will remain valid for
whole life of the concerned persons. After expiry of
the period of validity of the certificate the
persons in required to obtain a fresh certificate. A
original certificate will have to be produced for
inspection at the time of purchase of concessional
ticket and during the journey, if lemanded.
(3) No alteration in the form is permitted.
 AGREEMENT

An agreement made this date

on.......................................between
Shri_____________________(hereinafter calaled the
contractor) on the on part and GMTD Bhart Sanchar
Nigam Ltd., Azamgarh on the other part. Whereas
the contractor has offered to contract with the said
BSNL for hiring the vehicle at the approved rate as
shown in Annexure 'A' and on the terms and
conditions herein attached has been duly accepted.
The contractor has deposited with the A.O. (Cash)
O/O GMTD, Azamgarh Rs. 5000.00 (Five thousand
only) as earnest money, which has been converted
into security deposit and additional security will be
adjusted @ 10% from each bill of the contractor.
The contractor will during the period of this
contract or until this contract shall be determined
by such notice as in hereinafter mentioned, safely
carry out the contract according to the terms and
conditions attached.

Signature of the Tenderer

AGM
(Admn)
O/O GMTD,
Azamgarh

TENDER DOCUMENT FOR HIRING OF VEHICLE

(GMTD) AZAMGARH
 TERMS AND CONDITIONS

8.1 Rates quoted should include payment to

driver, repairs and maintenance of vehicle, const
of insurance, tax of all sorts, nothing extra would be
payable other than the change agreed to in the
tender.

8.2 Expenditure towards fuel will be borne by the

contractor.

8.3 The vehicle provided should be 2003-04

model or onwards and should not have run more
than 40000, it should be in good condition.

8.4 Drive shall be well dressed, well behaved and

having valid LMV driving licence. He should
have driving experience of at least three years. Any
laxity in the behavior of the driver shall be
constructed as breach of contract and shall lead to
cancellation of the contract. He will also observe
punctuality in timings.

8.5 The vehicle shall be parked in a garage, which

will be provided by the contractor in the vicinity
of place of work at his cost. The distance up to 5 kms.
in one direction shall be counted on individual
vehicle basis.

8-6 The log book in the prescribed form shall be

kept in the custody of the driver who shall filled
up the journey under taken by the official/officer
department and get them certified by the officer
who has performed the journey.

8-7 For out station journey and halts, the driver

himself make his own arrangements for stay,
meal etc. without any liability upon the officer
concerned of his department. All necessary help
as far possible, shall be provided to him.

8.8 Wherever permitted by the controlling officer

an amount @1/2th of the monthly charges shall
be deducted from the monthly payment for each day,
the vehicle was not provided. Wherever prior
approval of the monthly payment shall be deducted, as
penalty from monthly payment for each day of
vehicle was not provided. It will be in additional
of the per day deduction as mentioned above. However
if the contractor fails to provide vehicle beyond
two days, the vehicle shall be hired from open market
by controlling officer at the risk and cost of the
contractor. Any amount paid excess shall be
recovered from the monthly bill of the contractor.

8.9 The contractor shall submit monthly bill

verifed by the controlling officer by 7th of the
following monthly alongwith the logbook AGM (Plg.)
BSNL O/O GMTD, Azamgarh or any officer duly
authhorized by him. The bill shall be paid normally
within 15 days from the receipt.

Witness: AGM
(Admn)
O/O GMTD,
Azamgarh

1.

2.

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 3848

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 AGREEMENT

An agreement made this date on

01/01/2005 between Shri Vijay Kumar Singh S/o
Shri Abhimanu Singh, Sakin-Vill. & Post-
Ahiraulla, Azamgarh (hereinafter called the
contractor) on the on part and GMTD Bharat Sanchar
Nigam Ltd., Azamgarh on the other part. Whereas
the contractor has offered to contract with the said
BSNL for hiring the vehicle at the approved rate as
shown in Annexure 'A' and on the terms and
conditions herein attached has been duly accepted.
The contractor has deposited with the A.O. (Cash)
O/O GMTD, Azamgarh Rs.-25000.00 (Rs. Twenty
Five Thousand only) security money, vide receipt
no. dated . Now before these present
witness it is hereby agreed and declared by and
between parties as follows.
The contractor will during the period of this
contract or until this contract shall be determined by
such notice as in hereinafter mentioned, safely carry
out the contract according to the terms and
conditions attached.

Signature of the Tenderer

 AGM (Admn)
O/O GMTD,
Azamgarh
 AGREEMENT

CONSTRUCTION OF TWENTY FIVE VEDED

GOVERNMENT AYURVEDIC HOSPITAL AT
AZAMGARH CITY, DISTT. AZAMGARH
 ESTIMATE COST RS. 71.48 LACS

THIS AGREEMENT is made

this__________between the Ksetriya Ayurvedic
Awam Unani Adhikari, Azamgarh (herein after
called "The First Party") on the one part, and M/S
Construction & Design Service, U.P. Jal Nigam,
Registered Office at 7, Awas Vikas Colony,
Gulami Ka Pura, Harri Ki Chungi, Azamgarh
(hereinafter called "the Second Party") on the other
Part . WHEREAS the First Party desires to have
certain works (Annexure) to be shown and indicated
in the specification schedule/Drawings/ plan/designs
and such other documents to be prepared by the
designated agency and approved by the First Party
and which shall be treated as part of parts of this
Agreement.
NOW, it is hereby agreed by and between
the parties as follows:
1. Centage Charge: for the consideration of
12.5% (Twenty point five percent) centage charges
of project cost hereinafter mentioned the second
party shall subject to the conditions mentioned.
and from time to
time
 Contd...2
Page

(2)

herein, execute and complete the works, so

shown and described.
2. PROJECT COST:
(a) The project cost will be worked out on the
basis of updated U.P. P.W.D. rate and less 5%.
(b) The plinth Area Rates of U.P., P.W.D. shall be
applicable only when the actual specifications
of each type of the building strictly confirm to the
specifications on which such plinth area
rates are based. In case of any deviation in
specification, extra items shall be provided for in
preliminary estimates.
3. SOIL INVESTIGATION/SITE SURVEY:
The First party shall pay to second party the
actual cost of soil Investigation/site survey work to
be paid to the specifised agency plus 10% (Ten
Percent) as centage charges of the second party
in case, the sil Investigation and/or site survey is got
carried out through the second party.
4. DATE OF START: The date of start of
work shall be reckoned from the next day
after the expiry of 4 (Four) week of the issue of letter
of Intent or payment of total project cost of
issue of working drawings or availability of
Land for construction purposes to the second
party by the First, whichever is later.

and from time to

time
Contd...3
Page

(3)

5. TIME OF COMPLETION:

(a) The second party shall take up the work in

accordance with the priorities Indicated in
writing by the First party and its completion will be
governed by a join "PERI" to be prepared by the
second party showing the activities of the First
party and the second party. Which will be updated
according to the constraints of either party
from time to time.

(b) The second party shall and completely

finish the said buildings within two year after
full payments as per approved estimated cost. And
extended time (as per cause II) from the date
of commencement unless prevented by the any
labour strike. Freaccident, earth-quake, Mob-
violence, attacke from the air of any other
major disturbences (Force meajure) and default
there of.

6. ARRANGEMENT OF MATERIALS:
 (a) The second party shall arrange the cement
& steel from manufacturer . If the cement and
steel could not be made available in this fashion, the
same shall be purchased by the second party
from the open market.

(b) Electricity and water supply shall be

arranged for construction purpose at suitable
locations on the site by the second party.

7. INSPECTION OF WORK AND QUALITY

CONTROL:

The First party or his authorised

representative will inspect the construction
work at any time and from time to time.

Contd...
4

(4)

satisfy them selves that the building is

being constructed the second party as per
deisgns and specifications.
 Any defects or varaiations if found,
during the inspection will have to be
rectified by the second party on written notice by
the First party within 15 (Fifteen) days
from its receipt. In case the second party falls
to do it. The First party shall be entitled to
get it rectified through their own
resources on behalf of the second party and the
actual expenditure thus incurred will be
liable to be deducted from the bills of the
second party after satisfaction and verification of
second party.

8. EXTRA TIMES/DEVIATIONS:

In case, the First party shall desire for any

deviation from the said plans and
specifications, designs, or any one or more
building or buildings of any additional work
or works to be done of executed, the second party
shall execute such deviations or extra
additional work in a proper substantial and
workman lise manner in all respects according
to such altered plans and specifications and
within the time prescribed or any extension there of
as may be mutually agreed in writing and to
the satisfactions and within the time
 prescribed or any extension there of as may be
mutually agreed in writing and to the
satisfaction of the first party. The additional costs of
such deviations/ altermations if any shall be
estimated and paid to the second party in the like
wise manner. Items not provided in U.P.,
P.W.D. shall be paid on the basis of actual
cost of material, abour and other in puts plus 12.5%
(Twelve point five prcent) as centage chares.
Actual cost of materials shall be determined
jointly by representatives of construction &
Designe service & Medical Directorate.

and from time to

time
Contd...5
Page

(5)

9. EAMAGES FOR DELAY IN COMPLETION:

If the second party fails to complete the

works sithin the time specified in clause 5 or
within extended time the second party shall pay the
First Party a penalit at the rate of Rs.2% per
week subject to maximum of 10% of the total
project cost.
10. EXTENSION OF TIME:
If the work is delayed.
(a) By force majure, or
(b) By reason if any exceptionally in clument
weather of dispute with the
adjoining/neighbouring owneres public
Authorities arising otherwise than through the
second party's own default, or
(c) By the work or delays of the
contractors/GTradesmen other than second party
engages.
(d) By delay in release if funds, or
(e) By delay in deciding rates if non & schedule
items of
(f) By delay in other decisions by First. or
(g) By reason if civil commotion. or
 (h) From other cause which the First party may
certified as beyond the control if second party.
11. Work shall be carried at as per standard
approved drawing.
12. Estimated cost will be charged if schedule
rate of P.W.D. will be charged during construction
period.
13. Date of start if work will be the next date if
land handed over to the second party.

SIMPLE LOAN AGREEMENT (SD-13)

(For Agriculgural Advances)

UNION BANK OF INDIA
________________Branch.

IN CONSIDERATION OF Union Bank of India

(hereinafter called "the Bank") at the request
of..................................................................................
residing
at.....................................................................................
...........................
(hereinafter called "the Borrower/s") having from time
to time advanced/agreed to advance a loan of
Rs. ........................................(hereinafter called "the
loan" or "loan account" depending on the
context) granted by the Bank to enable the Borrower
to cary out the purpose or which the loan is granted on
the terms and conditions hereinafter contained.
NOW IT IS HEREBY AGREED BY AND BETWEEN
THE PARTIES AS FOLLOWS

1. The Borrower's application shall constitute the

basis of this agreement and of the laon to be
advanced by the Bank hereunder and the Borrower
hereby confirms the correctness of each and every
statement and particulars therein set forth.

2. The Borrower agrees and undertakes to notify the

Bank in writing of any circumstances affecting the
correctness of any of the particulars mentioned in the
Borrower's application within 7 days of the occurrence
of any circumstance.

3. The Borrower shall repay the said advance to the

Bank at............instalments
and on the days hereinafter mentioned.

Amount of Instalment Date of

Payment
4. (a) The Borrower shall repay to the Bank the loan
alongwith the interest on the amount of outstanding
for the time at the rate of................Percentage per
annum with.........rests or such other rates as may
be prescribed by the Bank from time to time
depending upon the changes in the Prime Term
Lending Rate of the Bank or the directives of Reserve
Bank of India from time to time, such interest shall be
payable whether debited to the loan account or not
and untill so paid shall from part of the loan and the
Borrower hereby waives the requirement of notice on
the revision of interest and the notice in the
newspaper or the Bank's notice Board shall be deemed
to be sufficient notice to the Borrower.

...2
Page
(2)

5. The Borrower further agrees that if default shall be

made in payment of three instalment on due dates
then the Borrower shall pay penal interest at such
rate as the Bank in its absolute discretion determines
on the amount then outstanding.

6. If default shall be made in payment of three

instalments on due dates then the entire amount of
the laon or the balance then remaining outstanding
(inclusive of penal interest) and owing to the Bank
shall at once become due and payable and on
demand being made by the Bank the Borrower shall
repay to the Bank all moneys or liabilities then
outstanding and owing to the Bank together with
interest (inclusive of penal interest) and all other
charges and expenses.

7. The Borrower agrees to accept as con clusive

proof of the correctness of any sum claimed to be
due from them to the bank under this Agreement a
statement of account made out from the books of
the Bank and signed by the Accountant or other
duly authorised officer of the Bank without production
of any voucher, document or paper and the
Borrower further agrees to pay to the Bank the
interest accrued as per this agreement but not actually
 debited to the loan account.

8. Any notice of demand or otherwise hereunder may

be given by the Bank to the Borrower at the last
known place of business or residence in India of the
Borrower and may be sent by post it shall be
deemed to have been given at the time when it
would be delivered in due course of post and shall be
sufficient to prove that the envelope containing
the notice was posted.

9. Should be Borrower be more then one individuala,

all shall be bound jointly and serverally and the firm
or members of the firm, such firm and all members
from time to time thereof shall be bound hereby jointly
and severally not withstanding any changes in the
constitution or style thereof and whether such firm
consists of or be reduced to one individual at any
time and also such individual members and their
respective heirs, executors and administractors.

IN WITNESS WHEREOF the borrower has hereto

subscibe his/hertheir respective hands to this Deed on
this_________day of_______________200___.
 LEASE DEED

THIS LEASE is made at Azamgarh, this

the ................ day of , 2005.

BETWEEN

Smt. Ramauti Devi W/o Sri Sant Prasad

Singh R/o House bearing Municipal No. 10/67, Ward
No. 8 , Mauza Madya, Jairam, Mohalla Rahul Nagar.
Tehsil-Sadar, Distt.-Azamgarh called "LESSOR"
(which expression shall mean and include his heirs,
executors, administrators and assigns of the ONE
PART.
 (2)

AND

INDIAN OVERSEAS BANK a body

corporate constituted under the banking companies

(Acquisition and Transfer of understandings) Act.

1970 having its Central Office at 763, Anna Salai,

Chennai and one of its Branc

h Office at Plot No. 383 and 384, Ward No. 9, Civil

Lines, Tehsil Sadar, City Azamgarh (U.P.) through its

Branch Manager Sri Raj Kumar Singh hereinafter

called the "LESSEE" (which expression shall mean

and include its successors and assigns) of the

OTHER PART.
 (3)

THE LEASE DEED WITNESSETH :

That in consideration of the rent herein

reserved and on the covenants on the part of lessee

hereinafter contained, the lessor demised unto the

lessee the building having a carpet area measuring

approximately 2092.75 Sq.ft. on ground floor

standing over at House bearing Municipal No. 314,

Ward No. 9 standing over S.M. Plot No. 383 and 384

situate at Mauza Madya Jairam, Mohalla Rahul

Nagar, Civil Lines, Tehsil Sadar, Distt.-Azamgarh

detailed and described in schedule below with

appurtenance belonging to it @ Rs. 6.25 per Sq.ft.

for the period of 5 years from 27.11.2004 to

26.11.2009 with 25% increase from 27.11.2009 to

26.11.2014 of monthly rent at Rs. 13079.69 per

month payable on the first day of the month for

which it shall be due. It is agreed between the

parties as follows :
 (4)

1- That the period fixed for the lease is 10 years

commencing from 27.11.2004 to 26.11.2014

on the same terms and conditions with 25%

increase in the said monthly rent from 27.11.2009

to 26.11.2014 of Rs.

16349.61 per month as herein contained. The

said lease period may further be extended on

mutually agreed terms by the lessor and lessee. The

lessee shall not pay interest on arrears of rent.

 (5)

2- That all rates and taxes municipal or

government chargeable or payable at present

or in future of the property hereby demised shall be

payable by the lessor and the lessor undertake

to pay the same including composition

fee, penalty for non-payment payable to any

statutory body(ies) in respect of the other

building and will ensure timely payment thereof to the

concerned body. However, on failure to pay

the same by the lessor, the bank as occupier

of such property shall pay the same and adjust it from

 the rents payable by the bank in due corse.

(6)

3- That the lessor will make repairs/white

washing/colour washing every year and

distempering/painting etc. Once in three years. In case

they fail to do so, the bank shall be entitled to

do these repairs and white washing/

distempering/ painting and every other kinds of

repairs after notice to the

lessor at its own expenses and the lessee

bank shall deduct the expenses so incurred

out of the rent.

 (7)

4- That any fixture in the shape of counter,

racks, partition electric, ceiling fans and

strong room equipments e.g. doors or sheets or cages,

which the bank may during the continuation of

this tenancy attach to the demised premises shall

belong to the bank and shall be removable by the

bank at the termination of the tenancy.

 (8)

5- That during the currency of this tenancy the

tenant shall occupy the

premises without any hindrance from the

lessor or any other person

claiming under him and shall also enjoy quite

and peaceful possession

 thereof.

(9)

6- That the lessee shall be entitled to bring in

and on the demised premises heavy irons safe or

any number of safes and of any dimensions and

weight and also its locker cabinets, strong room

door frames and leaves and other fixtures and

other articles of similar nature for its use in course of

its business and to install and fix to remain the

property of the lessee. The lessee shall be

entitled to remove at any time the various articles

installed and fixed up by it in and on the

demised premises on any time or on the

termination of original or extended terms of lease,

as the case may be which it may do by

removing the door, frames and leaves of the rooms

etc.
 (10)

of the demises premises if necessary to

remove the doors frames and/or

leaves or other fixture belonging to the lessor

for the purpose of taking out

its own articles, it shall fix same at his own

cost.

7- That lessee bank is entitled to make such

additions, alterations in the

premises as it considers necessary and that

the lessor will sign plans and

application etc. for submission for the local

authorities and got the same

sanctioned.

(11)
 8. That the lessor shall provide separate water

connection in the name of

lessee. The lessee shall, however, deposit

security money, if any for it.

Lessee shall also pay actual consumption

charges.
 (12)

9- That lessor shall ensure storage sufficient for

24 hours supply of water for

the lessee.

10- That lessor shall install grill gate and shutter

on the main gate of the

premises.
 (13)

11- That the bank on its absolute discretion and

irrespective of the period of

lease available can any time,

surrender/vacate the demise premises after

giving 3 month's notice to the lessor in

writing.

(14)
 12- That this lease deed is being executed in

duplicate and lessee shall be

entitled to keep the original and the lessor

shall keep the duplicate copy

and both copies shall be treated as original

for the all its legal and practical

purposes.
 (15)

SCHEDULE OF DEMISED PREMISES

Premises having a carpet area 2092.75 sqft.

on the ground floor of House

bearing Municipal No. 314, Ward No. 9 standing over

S.M. Plot No. 383 and 384 situate

at Mauza Madya Jairam, Mohalla Rahul Nagar, Civil

Lines, Tehsil Sadar, Distt-

 (16)

Azamgarh bounded as below :

East: Shop of M/s Rama Medical Hall.

West : Rest portion of House of the land lady

(Plot 383 & 384)

North : Rest portion of land lady (Plot 383 &

384).

South : Road.

(17)
 Notes : After expiry of lease period i.e. 10 years

a fresh lease deed shall be executed.

Witnesses :

1- Name

Father's Name

Address

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 KNOW ALL MEN BY THESE PRESENTS that
we__________________
______________________________________________________
________________
are held and tirmly bound upto UNION BANK OF INDIA,
in the sum of
Rupees_______________________________________________
______________________________________________________
__________________to be paid to UNION BANK OF INDIA,
its nominees, successors and assigns for which
payment to be well and truly made we jointly and
severally bind ourselves, our respective estates and
effects timly by these present Sealed with our Seals,
dated
this______________________________________________day
of________________________________________Two
thousand_________.
WHEREAS Mr.____
___________________________________________________
__________________purchased from the UNION BANK OF
INDIA____________________
a Demand Draft
dated________________________________________________
bearing No. _______________________for
Rupees_____________________________________________
______________________________________________________
______________drawn on
______________________________________________________
_____________________
and in favour of ___________________________________.
AND WHEREAS the said Mr.
______________________________________________________
_____________________
has requested the Bank to issue a fresh draft in lieu of
the said original draft said to have been lost or
miscarried AND WHEREAS
said____________________________________________
have agreed to indemnify the said bank in respect of
the payments of the said draft.

(2)

NOW the condition for the above written

Bond or obligation is such that if the said Bank, its
successors and assigns and its Directors and servant
and officiers and shareholders and their respective
estates and effects are and shall from time to time and
at all times hereafter kept safe and save harmless and
indemnified against any claim arising out of the said
Demand Draft said to have been lost or Miscarried
against all action, losses costs, charges, expenses and
demands whatsoever the said Bank may suffer on
account of the draft then and in such case the above
written Bond or obligation shall be void otherwise the
same shall remain in full force and virtue. We the
said________________________________ and
______________________________________________________
______________________
undertake to return the said original draft if found
hereafter.

SIGNED & DELIVERED bythe aforesaid

in the presence of witness

SIGNED & DELIVERED bythe aforesaid

 in the presence of witness

ANNEXURE 'H'

DECLARATION OF PARENTS/SINGLE PARENT OR

GUARDIAN IF PASSPORT IS FOR MINOR : TO BE
SIGNED BY BOTH THE PARENTS/SINGLE PARENT
OR GUARDIAN
 I/We affirm that the particulars given above
are in respect of (name of the
child)............................................... son/daughter of
Shri...................................................... and
Shirmati............................................ of whom I/we
am/are the Parents/Single Parents/ Guardians, I/We
undertake the entire responsibility for his/her
expenses. I/We solemnly declare that he/she has not
lost, surrounded or been deprived of his/her
citizenship of India and that the information given in
respect of him/her in this application is true. It is also
certified that I/We am/are holding/not holding valid
Indian passport(s) and the name of the child
mentioned is not included in Passport of either
parent.

Details of passport(s) held by the both or either

parent :

(Father) (Mother)
Passport No. .....................................
........................................
(In case both parents do not hold passports,
please write NO.)
Date & Place of Issue :..........................................
 .......................................
Child's name included in Mother's/Father's
passport.................................................................. on
age No..........................................................
OR

(Signature) (Signature)
Mother Father

SME-13
TITLE INVESTIGATION REPORT (TIR)

Name of the Branch

Name of the Raj Kishore Mishra,
Borrower/Mortgagor Advocate, Civil Court,
(Father's/Husband's name Azamgarh. Mob. No.
to be mentioned) 9839331664
Name and address of the
person who handed over
the papers to the
advocate for issuing the
TIR
 1. Description of the documents
verififed/scruitnized:

Sl. Date of the document Names of Original/cert

N parties ified
o. Photocopy/t
rue copy
1
2
3
4
5
6
7
8
9
10
11
12
2. That the said documents placed before me are
genuine, I have verified, tallied and compared these
documents from the records of the Office of the Sub-
Registrar of Assurances and also from the records of
other appropriate authorities.
3. Full/Correct description of the property.

Survey/Door
Patta/Khata No.
Plot No.___________/Flat
No. __________

Measurement/Extent of
property
Location/Land-
marks/name of the area,
Mohalla (if should give
clear location of the
property so as to reach
the spot in case of need)
City/District
Boundaries
East by West by South by North by

(2)

4. Description of the Chain of Title

from the Mother Deed to the latest title
deed (Chain to be traced for a period of
30 years for the commercial advances
and 13 years for the housing loans).

5. The links in the title history of last 13/30

years of chain of title have property established.
All the transactions have been duly verified from
the relevant records of the Registrar, Municipal
Corporation, City Survey, Town & Planning
and Revenue Department.
 6. If any of the transaction(s) are specify
the transaction such as oral partition,
tamily settlement, etc.) and state
whether such transactions are legally
valid and entorceable, if any document
in the form of duly shorn affidavit before
the Judical Magistrate/Notary Public,
containing no objection and affirming
the existence of such oral transaction
amongst/between the parties is to be
obtained from each of the party to such
transaction and if they have already been
obtained whether such transaction(s)
is/are duly supported by the relevant
records of Municipality/City Survey/
Revenue etc.

(3)

7. Describe the Nature of

Tenure (Absolute
ownership/leasehold
rights,
occupancy/possessory
rights Government
owned acquired or any
other Tenure to be
mentioned in detail
8. If the property is a
leasehold property
a) Whether lease deed
has been registered as
required under the law.
b. Residual period of
lease
c) Whether there are any
prejudicial clauses or
restrictive covenants in
the lease deed which is
likely to affect the lease
hold interests offered as
security.
d) Whether the
consent/permission from
the lessor is
obtained/available for
creating the mortgage.
e) Whether the property
is granted under
Government grant or any
other grant. Please
specify, if any permission
is required.
If it is so whether such
permission has been
obtained.
f) Whether any adverse
conditions in the grant-to
be mentioned in detail.
9. (A) If the
borrower/guarantor/mort
gagor has only a
occupancy right please
comment on the
safeguards to be taken
by the bank.
(B) Please specify the
local law which permits
mortgage and sale of
such occupancy rights.
10. Whether the local
laws or any other law
restricts the creation of
the mortgage/sale of the
property to be
mortgaged to the Bank.
11. Whether the
occupancy right is
heritable and assignable.
12. (A) If the Mortgagor
has only a possessory
right please comment on
the nature of such right
the validity there of and
also the precautions to
be taken by the bank.
12.(B) Please state the
name of the person who
has a primary/absolute
title.
12. (C) Whether
permission of such
person is required, AND
If it is so, whether
obtained?
12 (D) Please state in
what manner if would
affect the Bank as
mortgagee of such
possessory title.
(4)

13. If the
borrower/guarantor/mort
gagor has onbly a
possessory right please
comment on the nature
of such right the validity
there of and also the
precautions to be taken
by the bank.
14. Please state the
name of the person who
has primary and/or
absolute title in such
case and whether
consent or permission of
such person is necessary.
15. Pleaswe state in what
manner it would affect
the interests of the bank
as a mortgagee.
16. Mention if any
minor's interest is
involved.
17. If so, whether Court
permission ( except in
case of HUF property)
has been obtained for
offering the property as
security or is yet to be
obtained.
18. Please specify the
undivided share of the
Minor (whether there is a
claim or not)
19. Whether the persn is
holding the property in
the capacity of a
mortgagee.
21. State whether the
possession of the
property offered as
security is in
unhidered/undisturbed
possession of such
mortgagee and the
period for which he is in
such possession.
22. Are there any
restrictive conditions in
the mortgage deed.
23.The period covered
under the Encumbrance
Certificate and the
encumbrances if any,
reflected therein.
24. Name of the person
who has applied for the
encumbrance certificate.
25. Whether searches
had been conducted
physically at the office of
the
i) Sub Registrars office
Municipal/Collector/Taluk
or Such other Revenue
office.
ii) Registrar of
Companies.
iii) Civil/High Court
in the LISPENDENS
REGISTER.
iv) Local Development
Authority such as
Lucknow/Delhi/Bangalore
Development Authority
etc.
v) Village Accountant-in
the Dispute Register in
respect of Agricultural
property.
(5)

vi) When mulated in the

name of The person
creating the mortgage.
vii) Whether the property
has been notified for
acquisition by the
Govt./Dev, Authority/or
any other Govt. Authority.
viii) If so, whether search
has been conducted with
the Village Accountant/
Chavidi Register/Register
of Acquisitions.
ix) Whether the
holding/acquisition is in
accordance with the
provisions of the Land
Reforms Act.
x) Please state the nature
of any intervening
charges or encumbrances
observed/found against
the property.
xii) Whether the searches
had been conducted for
13 or 30 years. Please
produce the seach
receipts and other
documents in respect
thereof.
xiii) Whether the property
is subject matter of any
litigation and if so, the
details thereof.
26. Whether Urban Land
Ceiling Clearance is
required to be obtained
for creating the mortgage.
If the clearance has been
obtained the details
thereof be furnished.
27. Whether No Objection
Certificate under The
Income Tax Act, 1961 is to
be obtained. If yes. The
reference number be
mentioned.
28. Whether the property
is affected by any Local
Laws (Viz. Agricultural
Laws, Weaker Sections,
Minorities, land laws.
b) Whether any
permission is required to
be obtained from any
Authoritieis.
c) If so, whether any such
permission has been
obtained and the details
thereof be mentioned.
29. Whether permission
for conversion of Land/s
from Agricultural to
Residential or Commercial
is to be obtained. Please
mention the reference of
the proceedings.
30. Whether local revenue
extracts, mutation
extracts are available? If
so, whether verification at
taluk Office has been
made Please Furnish the
details.
31. In the case of
Partition/Settlement
deeds, whether the
original deed is available
for deposit. If it is oral
partition then give the
details as to how such oral
partition can be relied
upon the details of the
precaution, if any to be
followed.

(6)

a) Whether the deeds are

registered.
b) Name of the person
who is holding the original
partition deed.
c) How many sets of
partition deeds have been
prepared.
d) Whether mulation has
been made pursuant to
the partition and whether
all parties to the partition
are in the possession and
enjoyment of their
respective shares.
e) Whether all the
members of the family are
parties to the partition
(including the female
members-both married
and unmarried.)
f) Whether the partition
effected is under
Litigation and if so the
details thereof.
g) Whether the partition
effected is in respect of
the self acquired or
ancestral property.
32. If the mortgage is to
be created by an Agent
under a power of Attorney.
Please State.
a) Whether the Deed of
Power of Attorney is valid
and subsisting and
continues to be in force.
b) Name of the place
where executed.
c) If executed in a foreign
country, whether the
same is stamped after it
has been brought to
country.
d) Whether endorsement
of indian
Consulate/Notary of that
country given.
e) Whether the P/A is
property registered and
whether it gives the
specific authority for the
acts performed/professed
to be performed by such
attorney.
33. Whether the Deed of
Power of attorney
authorizes the agent to
deposit the title deeds for
the specific purpose of
creation of Eq. Mortgage.
34. What other precaution
to be taken.
a) In the case of
partnership firm, whether
the property belongs to
the Firm.
b) Whether the title deed
stands in the name of the
Firm.
c) Whether registered.
d) Whether any
restrictions are stipulated
in the partnership deed in
dealing with the property
by any partner.

(7)

c) Whether the property

belongs to any individual
partner in his own name.
35. Whether up to date
land revenue/Municipal
taxes and other cess paid.
a) Whether the tax
receipts/cist receipts have
been physically verified
and found to be in order.
b) Whether taxes/dues
payable to Govt.
Authorities or Statutory
Authorities viz. PF, Sales
Tax etc. are to be leviable
of are a charge on the
property.
36. In case of develoution
of property by wayt of a
will, the safeguards taken
to ensure against
impeachment of title
offered as security be
mentioned.
a) Please state whether
the will requires to be
probated.
b) Whether any Letters of
Administration has been
obtained in case the
person died intestate.
37. Where the property
belongs to a limited
company please state
whether the property has
been acquired subject to
an existing charges.
b) Whether the company
has filed necessary
charges under sec. 135 of
the Companies Act, 1956
and passed necessary
Resolution in that regard.
c. Whether any
restrictions operate
against the company in
creating mortgage.
d) Whether the company
has leasehold interest in
the property or is an
absolute owner.
38. The property in question is held/owned/alloted (as
the case may be) by the Company. The company has
producred relevant record (please refer and describe
the specific record such as Register of Charges
maintained under Section-143 of the Companies
Actm, 1956 minute book maintained under Section
193 of the Act, Register of Managing Directors,
Manager Secretary & Directors under Section 303 of
the Act, Register of documents sealed etc.) The said
records are in conformity with the relevant provisions
of the Companies Act, 1956 and the other relevant
laws/practices. There is nothing prejudicial to the
interest of the Bank.

39 I have also visited the Office of the Registrar of the

Companies, within whose office, the said Company
has been registered and has taken the searches of the
charges' created by the Company and other interested
persons as prescribed under Part V (Registration of
Charges) of the Companies Act, 1956 . The said
inspection reveals the following charges.

(8)
40. The 'Agreement for
the Sale " Agreement for
the building construction"
is in conformity with the
local laws (padicularly
relating to laws for
purchase of flats etc.) and
there is nothing
prejudicial to the interest
of purchaser eorrowen)
and the Bank . All
necessary parties have
been joined in it.
41. Whether equitable
mortgage is possible on
the strength of the title
deeds mentioned above.
a) If so, the list of
documents to be
deposited for the purpose.
b) The person/s who are
required to deposit the
title deeds with the bank
be mentioned.
42. What is the status of
Genealogical Tree.
43. Whether the same has
been issued by the
Tahasildar or any other
Competent Authority.
44. In the case of
flat/apartment, whether
the Agreement of sale,
deed of apartment and
Declaration is registered
with the Competent
Authority.
45. Any other
requirements to be
followed or complied with
 46. Advocates final
comments /views in detail
to be mentioned.
That the title of property
in question is legal and
marketable, free from any
anomalies and the Bank
can accept such property
in mortgage as good
entorceable security.
47. Any special
precautions/suggestions/
views of the Advocate in
the matter of creation of
mortgage.

Place: Seal
&
Date SIGNATURE OF THE
ADVOCATE

LOCATION SKETCH
(Please furnish the location sketch to enable our
Chartered Engineer/ Valuer to easily locate the propety
to be built/ purchased/ extended/ renovated. Please
ensure that it is drawn form a popular land mark)
1- Name of the applicant/ Borrower
2- Prominent landmark
3- Distance (apporox)
4- Bus route
5- Bus stop
6- Complete address
7- Any other information

ROUGH LOCATION SKETCH

Approach sketch to the location

Exact location of construction/ Purchase and working
paln
Please mention detars about the builder
Name of the firm
Address of the firm
Tel. No.
contact Person
Any other information
 KNOW ALL MEN THESE PRESENT that
we_______________________________________________ are held
and firmly bound upto State Bank of India in the sum of
rupees_____________________________ to be paid to State
Bank Of India, its nominees, successor and assigns for
which payment to be well and truly made we jointly and
severally bind ourselves, our respective estates and effects
firmly by these present sealed with our seals, dated
this_____________________________________________________
day of ____________________________________________one
thousand nine hundred and WHERAS
Mr_______________________________________________
purchased from the State Bank Of
India,______________________________________
a Demand draft
dated________________________________________________
bearing No.______________for Rupees
____________________________________
drawn on ____________________________________________and
in favour of
___________________AND WHEREAS the said
Mr.________________________
Has requested the Bank to issue a fresh draft in
lieu of the said original draft said to have been lost or
miscarried AND WHEREAS said _________________
___________________________________________
have agreed to idemnify the said bank in respect of
payments of the said draft.
NOW the condition for the above written bond or
obligation is such that if the said Bank its successors and
assigns and its Directors and servant and officers and
shareholders and their respective estates and effect are and
shall from time to time ana at ll times hereafter kept safe
and save harmless and indemnified against any claim
arising out of the said Demand Draft said to have been lost
or Miscarried against all action, losses cots, charges,
expenses and demands whatsoever the Bank may suffer on
account of the draft then and in such case the above written
Bond or obligation shall be
 (2)

void other-wise the same shall remain in full force and

virtue. We the said ____________________and
____________________________________ undertake to return the
said original draft if found hereafter

SIGNED & DELIVERED by the aforesaid

----------------------------------------------------
----------------------------------------------------
in the presence of witness

SIGNED & DELIVERED by the aforesaid

----------------------------------------------------
----------------------------------------------------
in the presence of witness
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 From No. 3848

I.............................................................................
....................................................... in consideration
of the sum of
Rs.................................................................................
............. paid to me
by.................................................................................
............................................. the receipt of which I
hereby acknowledge, do hereby as beneficial assig
upto the
said..............................................................................
............................................. aged......................
years his Heirs, Executors. Administrators and
Assigns the Policy of Assurance of the life of myself
granted to me by the Life Insurance Corporation of
India assuring the sum of
Rs................................................................... .............
............................... and
numbered............................................. and bearing
date the............................................. day
of.............................200.............. and the sum
assured thereby and all other moneys, benefits and
advantages to be received thereunder.

Dated at..............................
this......................day of.......................200....

WITNESS :
Signature ....................................................
Full Name....................................................
Designation.................................................
(Signature of Life Assured)
Address.......................................................
....................................................................

FROM OF NOTICE OF ASSIGNMENT TO THE

CORPORATION

Place.........................
Date..........................

The Divisional/Branch Manager,

Life Insurance Corporation of India,
..................................................................
..................................................................

Dear Sir,
Policy No........................................................

I Hereby give Notice that I have assigned the

above Policy No....................................
.....................................................................
Here mention the name and address of
.....................................................................
The assignee
.....................................................................
on.................................................................................
... Please acknowledge receipt of this notice and
forward the enclosed Policy/Deed of Assignment
to............................................. after registering the
assignment thereon in your books.

* Certified that the thumb impression.

herein is that of.................................
Yours faithfully
................................. who admits having
affixed the same after understanding the contents
hereof.
(Signature/*Thu
mb Impression
of Assigner)

* (Signature of witness)
ANNEXURE-I
 FORM-(I)
LIFE INSURANCE CORPORATION OF INDIA
Declaration by heirs of deceased Agent.

"We, the
undersigned.........................................................................
..............................
.................................................................................. ..........
...............................(Full names of all heirs)
.................................................................................... all of
........................................Hindu, Muslim, Christian, Parsi,
inhabitants in consideration of the Life Insurance
Corporation of Inadi (hereinafter called "the Corporation"),
having at our request, agreed to pay to us, the
undersigned jointly, us the heirs as on intestacy
of............................................. (hereinafter called "The
deceased") who was an agent of the Corporation, the
commission on the premiums received in repsect of the
policies introduced by the said deceased in the
corporation under sub section (2) or sub section (3) of
Section 44 of the Insurance Act, 1938, as made applicable
to L.I.C. of India by Gazette Notification dated 27.04.1972,
do hereby solemnly and sincerely declare and state as
follows."
1. That the deceased died on
the ................................................... day
of .......................200.......
2. That we the undersigned
names...............................................................would be
the sole heirs on the intestacy of the deceased leaving
separate property of his own and we the undersigned
names..................................................................... are
the legal representatives/heirs of
......................................................... deceased, who
was also one of the primary heirs of the deceased at the
death of the deceased, but died subsequently and as such
we are jointly entitled to the final
 [S-3]
SCHEDULE 'C'

DECLARATION

Tender for :
______________________________________________
Name of Tenderer :
______________________________________________
Specification No. and date of opening :
______________________________________________
 In Consideration of the U.P. Power
Corporation Ltd., having treated the Tenderer to be
an eligible person whose tender may be considered,
the Tenderer hereby agree to the condition that the
proposal in response to the above invitation shall
not be withdrawn within six months (or any
extension thereof) from the date of opening of the
tender, also to the condition that if thereafter the
Tenderer does withdraw his proposal within the said
period, the Earnest Money deposited by him may be
forfeited to the U.P. Power Corporation Ltd. and at
the descretion of the Purchaser, the purchaser may
debar the tenderer from tendering for minimum
period of one year reckoned from the date of
opening of the tender.

Signed
this__________________________________________day
of___________________200__.
Place___________________________Signed
by_____________________________

Witness:
Tenderer
Full
Signature__________________________________________
____

Name_____________________________________________
_

Designation_______________________________________
_______
 APPENDIX-'A'
LIFE INSURANCE CORPORATION OF INDIA
 This AGREEMENT is made at _______________ this
_______________ day of _________________ between THE
LIFE INSURANCE CORPORATION OF INDIA, a Corporation
established by the Life Insurance Corporation Act, 1956,
and having its Central Office at Mumbai and
Zonal/Divisional/Branch Office at ___________________
(hereinafter called "the Corporation" which expression
shall unless repugnant to the context or meaning thereof
be deemed to include its successors and assigns) of the
one part and Shri/Smt/Kum
______________________________________________
Son/Wife/daughter of
_________________________________________, residing at
__________________________________, (hereinafter called
"the employee" which expression shall include his/her
heirs, executors, administrators and assigns whereever
the context or meaning shall so require or permit) a
permanent whole-time salaried employee of the
Corporation of the other part;

WHEREAS
1- The employee is in the service of the
Corporation attached to the _________________
Branch/Division/Zone/Central Office at the
Corporation at ______________ and requires a Motor
Car for the proper discharge of his duties.
2- The Corporation has agreed to purchase the
Motor Car specified in the Schedule hereto (herein
after called "The said car") and place it at the
disposal of the above said employee to be used by
him/her for the purpose of the business of the
Corporation on the terms and conditions
hereinafter contained.
NOW IT IS HEREBY AGREED BY AND
BETWEEN THE PARTIES HERETO AS FOLLOWS:-
1- The Corporation shall purchase the said Motor
Car with all the tools and accessories belonging
thereto at or for the price of Rs. _______________ The
said Motor Car shall remain registered in the name of the
Corporation.
2- The Corporation shall allow the employee the
use of the said Motor Car during the period he/she
remains in the service of the Corporation and
 APPENDIX 'F'

APPLICATION FOR REDUCTION IN PERIOD OF

USAGE

I hereby request that the car, which is being

used by me under scheme ________, may be transferred
to Conveyance Scheme VI (Revised) with period of usage
as 5 years as envisaged in Circular ref. Mktg./ZD/34/200
dated: 07-10-2006 and other related instructions in this
respect.

2. Particular of the Car:

(a) Make:
_______________________________________________

(b) Year of Make:

_________________________________________

(c) Registration No.:

______________________________________

(d) Date of Purchase of the car by the Officer:

__________________

(e) Actual purchase price paid by the

officer (excluding cost of optional
accessories):
_________________________________________

(f) Amount of loan advanced by the LIC

towards purchase price:
 Rs.________________________
No. of prepayment instalments:
Instalment p.m.
Rs._________________________

(g) Tyres: (a) Distinctive numbers of tyres: (i)

(ii) (iii) (iv) (v)

(b) Type of Tyre:

Ordinary/Nylon/Radial/Tubeless:

(h) (a) Distinctive numbers of batteries:

(b) Make of the battery:

Contd..2/-

(2)

(i) Is the car roadworthy and good in running

condition ?
___________________________________________

3. The Scheme under which the car has been

since the date of purchase:
Scheme: ___________________
Date of entry: ___________________

4. I hereby agree for payment of net/written down

value in One Lumpsum
and/or addition of the net/written down value at
the end of the term to my income and for
deduction of Income Tax as per rules thereon.

5. I certify that the information furnished by me

above is correct.

6. I have read the terms and conditions of Scheme

VI (Revised) and agree to furnish such
information as is required under the Scheme and also
such other information as may be required by the
Corporation in connection with the Scheme and also
to execute the necessary agreement.

7. I undertake to maintain the car in good running

condition.
8. I agree to pay Income Tax or such other taxes as
may be leived by the Government/CBDT from time
to time and hereby authorise the Corporation to
deduct the same at source from my salary/any other
payment/s due to me or that may fall due to me.

9. I agree for the deduction of Group Insurance

premium from salary every month.

(Signature of the
Officer)

Name:
______________________________ .

Designation:
_________________________ .

Office and place of posting:

______________ .

Place: ___________ .

Date: ___________ .
 Form No.
3777
Proposal No...............................
__________________________________________________________
__________________
Name of the proposal in
full..........................................................................................
......
__________________________________________________________
__________________

1. Give particulars regarding the branch of the

Defence Forces. Regiment etc, to which you
belong and your present rank.
2. (a) Are you, at present, engaged in.
(i) Any flying duties as a Pilot or member
of aircrew or other duties reqiring you
to remain on board an aircraft otherwise
than as a passenger for the purposes of
transport.
(ii) Duties as a partaroopere:
(iii) Duties as a Gider Pilot:
(iv) Duties as amember of aviation operating
operating personnel or ground personnel.
(b) Where you engaged in the past in any of the duties
mentioned under (a) above, and if so, are likely or
libleto return to the same in future?
(c) Have you undergone or are you now undergoing
training for any of the duties mentioned under (a)
above?
(d) Have you, under the terms and conditions of your
service, any speciallibility to engage in Aviation,
Gliding or Parachuting?
N.B. : The liability referred to herein is not the
general liability imposed on all Defence Service
Personnel in terms or which they can be called upon
to take up any type of work in any of the Defence
Services.
3. Are you a member of any flying or Gliding Club? if so,
state:
(i) Whether you are undergoing training in flying, or
gliding, or whether you completed such training.
(ii) the number of flights made per annum.
 N.B. : in addition to the duties to be performed by you
as a member of Armed services in case your duties require
you to engage yourself in any other hazardous duties such
as (a) Manufacture and/or reconditioning of Ammmunition,
(b) construction work requiring use of explosives and/or
compressed air, (c) welding and spray painting, (d)
handing Electrical equipments carrving a voltage of 400
over and/or working at heights, (e) handing or remaning
exposed to fumes, gas acids or other chemicals, (f) driving
trucks or lorries or, (g) any other hazardous occupation , a
separate Occupational Qurey From (Form No. 500) should
also be completed in addition to completing this form.
__________________________________________________________
_____

DECLARATION

I.....................................................................do hereby
declare that the forgolng statements and answers are true
in every particular and agree and declare that these
statements and this doclaration along with my proposal for
Insurance and the Decla etion relative thereto shail form
the basis of the contract between me and the Life
Insurance Corporation of India and that if any untrue
averment be contained therein the said contract shall be
absolutely null and void and all moneys which shall stand
forfeited to the Corporation.
Dated at.......................................on the.................day
of...............
Signature of Witness.................................
Occupation...............................................
Address..................................................................................
.................
Signature or thumb impression
of
If this form has been filled in any language other than
English, the Proposer should further declare in his own
language above his own signature that all the questions
were explained to him and his replies were given after fully
and properly understanding the same.

In case the Proposer is illiterate:

1.This declaration should be made by the 1. I
hereby declare that I have person filling in the form:
fully above question to the proposer &
have
truthfully recorded the
answers given byt the
proposer.
Address of .................................
the
Declarant ................................. Signature

2. The thum impression of the proposer 2. I hereby

declare that I have explained the
shuld be attested by a person of standing contents
of this form to the proposer in
whose identify can be easily established,
..................(Ianguage) and that I have read
this declaration shuld be made by him. out to the
proposer the answers to the
questions dictated by the proposer and that the
proposer has affixed his thumb
impression to
Address Address of ........................ this form after
the fully understanding the the
fully understanding the contents thereof
Declarant........................
__________________________________________________________
__________________
eSa
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------------------------------------------------
vk;q---------------------------------ftudk
irk--------------------------------------------------------------
-----------------------------------------------------------------
----------------------------------------------------dsk ml
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gks tkus dh n'kk esa bl ikfylh }kjk lajf{kr
/kujkf'k dk Hkqxrku fd;k tk;sxk A

LFkku%------------------------------------------
fnukad---------------------------------------200--------
 chenkj ds
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 AFFIDAVIT

I,___________________________________S/O
Shri_______________________________
aged____________working___________________________
_________as____________________of
M/S
____________________________________________________
___having its registered office at
_____________________________________do solemnly
affirm and declare an oath as under:

1. That I am competent to swear this affidavit

being_________________________________
2. That I/My
Firm________________________________________________
_is applying for the Dealership of KRIBHCO SHYAM
Fertilizers Ltd. (KSFL)
at______________________________

Tehsil___________________Distt.________________State
_________________for sale of
KSEL Urea, which is being marketed by KRIBHCO
on behalf of (KSFL).
3. That I am fully aware of contents of documents
submitted by us for Dealership and I declare that
all the contents of the same are true and correct
as per the records.
4. That I hereby confirm and declare that none of
our grou/sister companies/concerns except me,
have applied for Dealership.
5. That I hereby confirm and declare that none of
my group/association/sister concerns have been
black listed/Suspended by any of the fertilizer
company, i.e. Private, Public or Cooperative
Sector due to violation of FCO, Shop, Weight &
Measurement act or for breach of terms and
conditions of Dealership or for any other reason.
6. That I hereby confirm and declare that
name/firm/concern's fertilizer license has never
been cancelled/suspended due to non
compliance of F.C.O.
7. That I further undertake that in case any of facts
contained in our applications is found otherwise or
incorrect or false at any stage, I/My firm/Sister
Company (ies)/concern(s) firm(s) will stand debarred
from the present and future dealerships of KSFL.
8. That I and/or none of the partners of the firm
and its another/sister concern have been
convicted for any offence by the court of law,
and that I have no legal dispute pending with any
other organization and that I have never been in
legal dispute with any other fertilizer organization.
For
(Deponen
t)
` Verified
at__________________on______________that the
contents of paras 1 to 8 of this affidavit are true and
correct to my knowledge and no part of this is false
and nothing has been concealed or falsely stated
therein.
For
(Deponent)

(2)

performs and observes all the conditions of his/her

service and all the covenants on this part and the
conditions herein contained.
3. The employee shall agree that at the end of the
fifth year or thereafter the written down value of
thecar calculated as per Corporation's Rules/
Instructions as on the date of exit, would be
added to his/her income in the respective
financial year and the Corporation shall deduct
income tax at the applicable rate as per rules and
remit it to the income tax authorities. On recovery
of Income tax from the user Officer, the car shall
be transferred in the name of the user
employee.
4. On exit before the completion of period of 5
years from the Scheme, the employee shall agree
to remit to the Corporation the written down value
of the car calculated as per Corporation's
Rules/Instructions applicable as on the date of
the exit in lumpsum and on receipt of the said
written down value of the car, the car shall be
transferred in the name of the user employee.
5. During the course of the vehicle being in the use
of the employee, the employee will:
 (a) bear and pay all the expenses of keeping
the said Motor Car in good order and
condition and do or cause to be done all necessary
repairs to keep the said car in good order and
condition to the satisfaction of the
Corporation.
(b) provide a safe garage or parking place for
the said Motor Car/Motor Cycle/Scooter.
(c) Use the said car solely for the business of
the Corporation and for reasonable town
running for personal purposes and bear and pay all
charges for the upkeep of the said car.
(d) pay all fines that may be imposed or levied
for driving or using or allowing the said
Motor Car to be used in contravention of the law
or police regulations or any other regulations in
force from time to time.
(e) allow the Corporation's representative at all
reasonable times to inspect the said Motor Car
and view the state and conditions thereof.
(f) shall not sell pledge mortgage or part with
possession of the said car or otherwise deal
with the same in any manner whatsoever.
Form No. 3807
The Divisional Manager/Branch Manager

LIFE INSURANCE CORPORATION OF INDIA

D.O./B.O. ________________
_____________________
 Letter to be
completed
and signed by
the Surety
Dear Sir,
----------------------------------

I beg to inform you that I am prepared to execute an

Indemnity Bond in favour of the LIFE INSURANCE
CORPORATION OF INDIA to enable it to pay to
Shri/Smt________
_______________________________ of the claim under its
policy No.____________
_________________ without insisting on legal evidence of
Life.

Consequently I have filled in the questionnaire

form given below:

QUESTION ANSWER

(1) Are you related to the policy holder/claimant? (1)

_______________________
if so, state your relationship with him/her

(2) What is your present occupation and (2)

_______________________
permanent address ?
Contd...2...

(2)

(3) What is your approximate monthly income (3)

______________________
and what are the sources ?

(4) What property, movable or immovable (4)

_______________________
do you possess and what is the present value ?

(5) Is the property free from encumbrance ? (5)

_______________________

I do hereby solemnly assure the Corporation that I have

thoroughly understood and correctly answered the
above questions.

Declared at __________________ this _________________ day

of __________ 200___

WITNESS

Signature of the declarant

________________

Signature _______________________

Father's of the declarant

__________________

Name _____________________________________
Occupation or Designation _____________________

Present Address
________________________
_____________________________
_________

Address _________________________________
Full name of the Surety _____________________

N.B.: This from be completed before (1) An Advocate,

(2) An Agent of the Corpn., (Who is a member of the
club at the level of Divisional Manager's Club and
above) (3) A Bank Manager, (4) A Block Development
Officer (5) A Commissioner of Oaths, (6) A Doctor, (7) A
Gazetted Officer, (8) A Head Master of a High School, (9)
A Head Postmaster of Departmental Sub-Postmaster
(but not a Branch Post Master) (10) A Magistrate (11) An
Officer of Development Officer atleast 3 years standing
(12) A confirmed Development Officer recruited from
the Agents who were D.M., or B.M. Club Members before
joining (13) A Development Officer recruited from
agents who were ZM of Chairman Club Members before
joining, or (14) President of a Village Panchayat of Local
Board.
 LIFE INSURANCE CORPORATION OF INDIA
Hindustan 3,000-12-88
LETTER OF INDEMNITY

To
The Divisional Manager,
Life Insurance Corporation of India,
______________________.

Dear Sir,
WHEREAS you had issued to me
on__________________200__ a cheque
No._________________for Rs.__________________(Rupees
___________________
__________________________drawn on
the______________________________Bank
of_____________________________Ltd._____________________
_____in payment of Medical Fee/Commission/Travelling
Allowance______________________________
______________________________due to me.
AND WHEREAS the said Cheque has been lost
or mislaid .
AND WHEREAS upon my representation that the said
Cheque has been lost or mislaid and has not been
transferred or dealt with by me in any manner and on
my undertaking that if the said Cheque is found, it shall
be returned to you for cancellation, you have agreed at
my request to issue to me a duplicate Cheque in lieu of
the said lost or mislaid cheque, on my giving you this
Letter of Indemnity.

(2)

NOW in consideration of the premises I for my

self, my heirs, executors and administrators agree and
undertake from time to time and at all times hereafter to
indemnify and keep you and the Life Insurance
Corporation of India harmless and indemnified from and
against all claims, demands, actions, liabilities and
expenses which may be made or taken against or
incurred by you or the said Life Insurance Corporation of
India by reason of the issue of such duplicate Cheque or
in respect of the said Cheque No. _____________________.
Dated
at_______________________this___________day of______200

Witness:

Full Name :_________________ Yours

faithfully
Signature :_________________
Occupation :_________________
Address :_________________
:_________________
:_________________
 INDIAN OIL CORPORATION LIMITED
(MARKETING DIVISION)
PETROL (MS) HIGH SPEED DIESEL OIL RETAIL
OUTLET DEALERSHIP
AGREEMENT FOR DEALER CONTROLLED OUTLETS

MEMORANDUM OF AGREEMENT MADE

THIS__________DAY Parties of_______________________Two
thousand_________________
Between Indian Oil Corporation Limited, a Company
registered under the Companies Act, 1956 and having
its Registered Office at Indianoil Bhavan, G-9, Ali Yavar
Jung Marg Bandra (East), Bombay-400 051 and a State
Office at___
___________________________Street/Road
__________________________
Town and_________________State (Hereinafter called "The
Corporation") of the one Part;
AND___________________________________________________
_________
of______________________________________________________
_______
Inhabitants carrying on business under the firm name
and style of___________
________________________________________________________
_______
(Hereinafter called "the Dealer") of the Other Part.

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 3805
In consideration of the Life Insurance Corporation
of India successors to the controlled business / business of
........................................ under the provisions of Act 31 of
1956
having agreed to
pay.............................................................. (Name of all
payees)
...............................................................................................
..............................of....................(Relationship)(Name of
deceased policy holder) the sum of
Rupees ........................................ .........................................
.................................due under policy
No. ........................................ on the life
of ............................................deceased, without requiring
production of probate or letters of administration of
succession certificate grated to the estate
of ..............................................................................(Name
of deceased policy holder)
We.........................................................
and ...................................................our heirs,
(Name of all payees) (Name of
surety) Executors, administrators do hereby
agree....................................... to keep the said Corporation
harmless and indemnified from and against all claims
against it on the part of any person or persons
whomsoever and all damages, costs and expenses which
the said corporation may sustain or incur in consequence
of any such claim or claims.
In witness whereof we the
said ............................................................................
(Name of all payees)
and .........................................................................have
(Name of surety)have set our hands
at .......................................... this .........................................
day of ................................ 20.............
(2)

Signed and delivered by the

said........................................................................ ...............
...............................................................................................
........................................
 (Name of all payees)
and .......................................................................................
.........................................................
(Name of surety)

In presence of :
1. ......................................................
(Siganture)

Full signature
Witness(1) ............................
2. .....................................................
(Siganture)
W
I
T Designation..............................
N
E Address ................................... Signature of
the surety
...........................................
Full signature
S, of Witness(2) ............................
S
Designation....................................
E Designation..............................
S
Address ...................................
Address .........................................
.................................................
..................................................
 3806
OFFICE/UNIT ....................................................
..........
FORM OF APPLICATION TO DISPENSE WITH
LEGAL EVIDENCE OF TITLE

Policy no.............................................. for

Rs. ......................................................... on the
life
.............................................................Deceased)I ......
..................................................... of
.......................widow/eldest son/ .................................
of the above named .............................. do hereby
solemnly declare that the above policy holder died
intestate and I request that legal evidance of title
required in terms of the above policy be dispensed
with and I hereby solemnly declare that the following
statement are true to the best of my knowledge and
belief:
_____________________________________________________
____________________
1. (a) Full name, address and occupation
of the deceased at the time of his
death____________________________________
(b) What was the deceased's caste and
religion?
_____________________________________________________
________
(c) Was he a Hindu, Sikh, Jain or Buddhist,
the succession to whose estate is governed
by the Hindu Succession Act, 1956 ?
_______________________________________
(d) Was he a Mohammendan the succession
to whose estate is governed by the
Mohammedan Law?________________________
_________________________________________________
___________________

(2)
2. When and Where he die?
 _____________________________________________
_________________________________________________
___________________

3. Has he left a will ?

___________________________________________________
_________________________________________________
____________________

4. (a) Has the deceased left any other

estate(a)_________________________________
besides the moneys due under the above
policy for which evidence of title such as
succession certificate is or has been obtained?

(b) Was the deceased insured with

any(b)____________________________________
other Unit of Divisional Office of the
Corporation? If so state:
1. The name of the Unit or Divisional
1.____________________________________
Office.
2. Number/s of the policy/ies and
1.____________________________________
amount due under each of such
policy/ies and.
3. Number/s of the Assignee/s of Nominee/s
3.______________________________
under the above Policy/ies.
Note: In the case of HINDUS, if any of the relations
mentioned in statement. 5 herein were adopted,
please state full details regarding such adoption.
_________________________________________________
____________________

5. Has the deceased left any of the following

relations and if so, give their full names and
ages.
(a) Sons Full Names
Ages
1.
2.
3.
4.
(b) Daughters 1.
2
3
4

(3)
_____________________________________________________
______________________
(c) Widow or widows/widower
_____________________________________________________
______________________
(d) Mother
_____________________________________________________
______________________
(e) Sons, daughters & widows of predeceased
sons
(i.e. of sons who died before the assured
_____________________________________________________
____________________
(f)Sons, daughters of predeceased daughters
(i.e. of daughters who died before the assured)
_____________________________________________________
_____________________
(g) Sons, daughters of predeceased daughters
(i.e. of daughters who died before the assured)
_____________________________________________________
____________________
(h) Father
_____________________________________________________
_____________________
(i) Brothers
_____________________________________________________
_____________________
(ii) Sisters
_____________________________________________________
_____________________

If any of the aforesaid relations are minors, state

with whom the minors are living and by whom they
are being maintained
_____________________________________________________
_____________________
6. If the decease has not left any of the aofresaid
relatives, but jas left remoter relations such as
Grand parents brother's or sister's children etc.
give the name and agaes of all such remoter
relation.
_____________________________________________________
______________________
7. State which of the relatives as noted in
answer to question 5 & 6 are claimaints to the
policy moneys and whether there is any
dispute between any of the relatives in this
connection

(4)

8.Give the full name, age and address of a

person of sound financial standing who is
prepared to execute an indemnity bond
jointly with the heirs of the deceased.
_____________________________________________________
______________________
Dated __________________ this _________________ day of
______________ 20________

Witness:
Name ____________________________________
Signature _________________________
Designation _______________________________ Address
__________________________
Address
_____________________________________________________
_______________

N.B.A. This application must be countersigned by a

doctor, a bank manager, a head post master or a
departmental sub post master (but not a branch post
master) a clergyman, gazetted officer, a president of
the locak board, a chief executive officer of a
municipality, a justice of the peace, a magistrate, a
commissioner or oaths, a notary public. Collector, a
judge, a head master of high school, an advocate, a
president of a village panchayat, or an officer or a
superintendent or a development officer (who is
confirmed and has served for at least five years as a
development officer) of the corporation provided he
knows the applicant.
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 FORM OF AFFIDAVIT

Before the District Election

Officet........................................(District, State/Union
Territy Affidavit of Shri...................................
(S/o)...............................................

I...........................................son/wife/daughter
of.......................aged.....................
years, r/o..........................................do hereby
solemnly and sincerly state and declarely state and
declare as lunder:-
(1) That I was a contesting candidate at the general
election/bye elevtion to the House of the PEOPLE?
Legislative Assembly of .................................... from
............... Parliamentary/Assembly constituency, the
result of which was declared on.....................
(2) That I/my election agent kept a separate and
correct account of all expenditure incurred/
authorised by me/ my election agent in connection
witth above election
between..................................(the date on which I
was nominated) and the date of declaration of
the result thereof, both days inclusive.
(3) That the said account was maintained was
maintained in the Register furnished by the
Returning Officer for the purpose and the said
Register itself ia annexed hereto with the supporting
vouchers/bills mentioned in the said account.
(4) That the account of my election expendifure as
annexed hereto includes all items of election
expendifure incurred or authorised by me or by my
election agent, the political party which
sponsored me, other associations/ body of persons
and other individuals supporting me, in connection
with the election, and nothing has been concealed or
withheld/suppressed therefrom (other than the
 expense on travel of 'Leaders' covered by
Explanations 1 and 2 under section 77 (1) of the
Representation of the People Act, 1951).
(5) That tje Abstract statement of Election
Expewnses annexed as Annexure II to the said
account also includes all expenditure incurred or
authorised by me, my election agent, the political
party which sponsored me, other associations/body
of persons and individuals supporting me, in
connection with the election.
(6) That the statements in the foregoing paragraphs
(1) to (5) are true to the best of my knowledge and
belier that nothing that nothing is false and nothing
material has been concealed.

Deponen
t

Solemnl affirmed/affirmed/sworn
by....................at ..................... this day of
200 .............Before me, (Signature and seal of the
Attesting authority, i.e. Magistrate of the Class or
Oath Commission or Notary Public)

LEFTER OF DISCLAIMER

The Branch Manager/Chief Manager/Asstt. General

Manager
State Bankof India, Azamgarh Main Branch
_________________________________________________________
________
Dear Sir,
Saving Bank Account No. 10955118457 in the name of
Shri Shiv Prasad Gupta Balance
Rs. ......................................................................................
....................... With reference to the above account (s),
I/We the following legal heirs of the late Shri Shiv Prasad
Gupta . (Name of the deceased account holder) have to
advise that we have no interest in the above assets and
as such we have no objection to your paying the balance
amount lying in the above account(s) with you in the
name of the aforesaid Shri Shiv Prasad Gupta (name of
the decesased account holder) to Shri

1. Mrs Indrawati Devi W/o Late Sri Shiv Prasad Gupta.

Such delivery of the payment of the balance in the above
account(s) would be completely binding on us and we
will not question the bank's action in so doing in any
proceeding I/We also undertake to bind ourseleves, our
heirs and legal representatives not to revoke the
declaration made herein.
Sr.No. Name(s) of the Claimants Age
Signature
1..Bhagwati Prasad Agrawal 49 Yrs
2. Rajiv Kumar Agrawal 46 Yrs
3. Sanjiv Kumar Agrawal 44 Yrs

Singed before me
This........................................day
of............................................(Notary Public/Magistrate)

AFFIDAVIT
 I/We (1) Arun Kumar Gupta son of Late Shri Gulab
Chand Gupta R/o Asifganj, Azamgarh do hereby make
oath*/solemnly affirm and say as follows:-
That Shri Shiv Prasad Gupta (Name of the deceased)
(hereinafter referred to as "the deceased") died intestate
on 01-03-2007 at Khatri Tola, Azamgarh.

2. That we know the deceased and his family since the

last 20 (Twenty) years.

3. That at the time of his death the deceased left

surviving him the following persons who according to
the law by which they are governed, are the only legal
heirs of the deceased entitled to succeed to the estate
of the deceased on an intestate succession:-

Name Age Relationship

with the deceased
i. Mrs. Indrawati Devi 70 years Wife
ii. Bhagwati Prasad Agrawal 49 years Son
iii. Rajiv Kumar Agrawal 46 years Son
iv. Sanjiv Kumar Agrawal 44 years Son

4. That we are not related in any manner whatsoever to

the deceased or any of the above mentioned persons
nor have we any claim or interest of whatsoever nature
in the estate of the deceased.

5. That we are informed and we verily believe that the

decedased has left certain deposits*/ assets withe
the State Bank of India Azamgarh Main Branch, to which
the abovementioned persons are entitled to claim.

6. That we are making this solemn declaration

sincerely and conscientiously believing the same to be
true and with full knowledge that it is on the strength of
this declaration that State Bank of India, Azamgarn Main
Branch, has agreed at our request to make payment of
the amounts of the deposits/to deliver the assets to the
abovementioned persons without insisting on
production by them of a grant of legal representation to
ther estate of the deceased from a competent court.

Sworn*/Solemnly affirmed

This agreement made

at___________________________this____________________day
of_____200 between THE LIFE INSURANCE
CORPORATION OF INDIA, a corporation established by
the life Insurance corporation Act, 1956 and having its
central Office at Bombay and Branch Office
at______________________(hereinafter called "the
corporation" which experssion shall unless repugnant to
the context or meaning thereof be deemed to include its
successirs and assigns) of the one part and
Shri/Smt./Km._______________________son/of______________
________________residing
at_______________________________________________________
____________________________
(hereinafter called "The employee" which expression
shall include his/her/heirs, executors, administrators and
assigns wherever the context or meaning so require or
permit) on the other part.

1. The employee is in the service of the corporation

as___________________________
at____________________________and requires a
Scooter/Motor Cycle/Moped for the proper discharge of
his duties.

2. In consideration of the employee agreeing to use the

Scooter/Motor Cycle/Moped solely for the purpose of
the business of the Corporation or the terms and
conditions hereinafter contined, the Corporation has
agreed to advance the employee a sum of
Rs._________________________

(Rupees_________________________________________________
______________) towards the purchase price of the
Scooter/Motor Cycle/Moped hereinafter mentioned to be
sucured by Hypothecation of the said Scooter/Motor
Cycle/Moped.
Now, It is hereby agreed by and between the
parties hereto as follows:

1. The shall loan of

Rs._____________(Rupees_________________________________
________)
shall be debited to an account to be called "The
Scooter/Motor Cycle/Moped loan account to be called"
the corporation every month on or before the
________________________ day of each month a sum of
Rs._____________ (Rupees_____________________________)
inclusive of interest at the rate of % (Simple) p.a. which
 shall be credited in the said Scooter/Motor Cycle/Moped
loan account on cash monthly instalment from the
salary and other emoluments due to the employee and
credit such amount in the said Scooter/Motor
Cycle/Moped loan Account.

Jai Prakash Yadav Resi. Vill. Belhari

Imam Alli
Advocate P.O.
Chittepur, Azamgarh
Civil Court, Azamgarh Ph. No.
(05460) 246494
Legal Advisor Mob.
9451241470
Union Bank of India
&
Kashi Gomti Samut Gramin Bank

To
The Branch Manager,
Branch________________,
Distt. Azamgarh.
Sir,
Reg. Agriculture Loan Facility to
Sri_____________________________________________

With reference to the Agicultural land Application

of Sri ______________________________
S/O Shri________________________R/O
Vill._______________________________ Parg. ______________
Tehsil________________Distt. Azamgarh on the Security of
the immovable properties where of are given in Schedule
hare to I Jai Prakash Yadav Advocate hereby confirm to you
in my capacity. As your Advocate that. I have Searched the
books Available in the office of Sub-Registrar
______________________for 12/30 proposed proceeding years
and on the basis of above such and affidavit affirmed by
the above person. I certify that the title of said Borrower to
the said Properties is clear Marketable and free from
Encumbrances from reasonable doubt & also free from any
defect what so ever Cash Receipt
No.____________Dated_____________issued by the sub
registrar is inclose that following land exist in the name of
following. I have also tallied the record with original and
found correct.
SCHEDULE OF PROPERTIES

land situated
village____________________________________________________
_____________________

Parg._____________________________
Teh._______________________Distt._______________________.

Village in Owned Khata Plot Area Total

which land by No. No.
situated
Land (In Words) Jai
Prakash Yadav
Dated:........................
Advocate
Civil Court,
Azamgarh (U.P.)
Agreement made the________________day
of________________Two Thousand_________ between
the Life Insurance Corporation of India, a
corporation established by the Life Insurance
Corporation Act, 1956 and having its Central Zonal
Office at Kanpur and Divisional office at Gorakhpur,
hereinafter called "the Corporation" (which
expression shall include its sucessors and assigns
whereever the context or meaning shall so require
or permit) of the ONE PART and Shri
___________________________________. HEREINAFTER
called "the Agenmt" (which expression shall include
his heirs, executors and administratiors wherever
the context or meaning shall so require of permit) of
the OTHER PART.
WHEREAS
The agent is in the employee of the
Corporation as_____________
and requires an____________________________. FOR
THE proper discharge of his duties.

The corporation has agreed to purchase

the______________________
specified in the schedule hereto (hereinafter called)
the ________________) to be used by the agent for
the purpose of the business of the Corporation no
the terms and conditions hereinafter contained and
contribute to it self upto the full purchase price of
the said_______________.
NOW IT IS HEREBY AGREED BY AND
BETWEEN THE PARTIES HERETO AS FOLLOWS:
The Corporation shall purchase the
said___________________ with all the tools and
accessories belonging there to at or for
Cont...2
 INDEMNITY LETTER FOR ISSUE OF
DUPLICATE TERM DEPOSIT RECEIPT ISSUED
IN LIEU OF EARNEST MONEY

TO BE STAMPED AS AN
AGREEMENT
PROVIDED SIGNATURES
ARE NOT
WITNESSED

Name___________________________
Address_________________________
________________________________
Date____________________________
Bank of India
_______________

Dear Sirs,
Re. Term Deposit Receipt No.
Dated_____________for
Rs._____________
in favour
of___________________________
due
on________________________________

We, the undersigned,

Mr/Mrs.___________________and________
__________________(Name of the Government
Department) respectively have entered into a
Contract
No._______________dated_____________for_________
One of the terms of such contract requires the
undersigned No.1 to obtain a Term Deposit
Receipt from the Bank in favour of the
undersigned No.2
___________Account_______________(Name of the
Depositor) to the extent of_____________________for
the purpose of_____________________
2- Pursuant to the above requirement, I, the
undersigned No. 1_______ had obtained the Term
Deposit Receipt from your bank in favour of the
undersigned No. 2___________(Government
Department) who has
(2)
also executed these presents:-
3- We were until recently in possession of the
above mentioned Term Deposit Receipt/s is
used by you in our favour.
4- We regret inform that the above mentioned
Deposit Receipt/s has/have been other lost or
misplaced and cannot be traced inspite of our
having a due and diligent reach for the same.
5- We assure that we have not created any right
or interest in the said Receipt/s or in the debt
represented by it, in favour of any person
whomsoever.
6- We have requested you to issue a duplicate
Term Deposit Receipt/s in lieu of the aforesaid
receipt/s which has/have been lost
7- You have agreed to accede to our above
request on the faith and strength of our above
representations and assurances and on giving you
the indemnities, undertakings and authorities as
hereinafter appearing.
8- In consideration of the premises, we so as to
bind ourselves jointly and severally and our heirs,
executors, administrators, estates and effects and
severally hereby agree and undertake with
you successors and assigns as under:-
i) to keep you safe and indemnified from time
to time and at all times from and against all
claims, demands, action, proceedings, losses,
damages, liabilities, costs, (legal costs being
between Attorney/Advocate and client, charges
and expenses whatsoever which may be made or
brought or commenced against you or to be
paid, sustained, suffered or incurred by you
howsoever as consequence, direct or indirect, of
your issuing to us duplicate Term Deposit
Receipt/s as aforesaid;
ii) to pay to you and make good the amount of
such loss, damage] liability, costs (legal costs
being between Attorney/Advocate and client),
charges and expenses together with the interest
at________% p.a. rate of interest as on an
unsecured advance from the date of payment by
you until reimbursement by us.
iii) to return to you the original Term Deposit
Receipt/s as aforesaid should it be found by us
or should it again come into our possession at any
time hereafter.

Your's
faithfully,

In consideration of the premises, I/We the

undersigned (jointly and severally) guarantee to
you, Bank of India the payment of all moneys due
under the aforesaid presents by executants
thereof.

1- Signature :
Name :
Occupation :
Address :
2- Signature :
Name :
Occupation :
Address :
 iwokZapy fMxzh dkyst
jkelqUnjiqj] jkuhdhljk;] vktex<+

i=kad% fnukad

miHkksx@ekWax i=

lsok esa]
ftyk iwfrZ vf/kdkjh]
vktex<+ A

fo"k;%& egkfo|ky; ds rsy ds vkoaVu ds

lEcU/k esa A
&&&&&&&&&&&&&&&&&&&&&&&&
&&&

egksn;]
vki }kjk ekg flrEcj] 2009 dk vkoafVr
feV~Vh ds rsy dk forj.k egkfo|ky; ds Nk=ksa esa
fu;ekuqlkj Jh vk'kh"k dqekj mik/;k; ds }kjk dj fn;k
x;k gS A
vr% ekg fnlEcj] 2009 ds feV~Vh ds
rsy dks vkoafVr djus dh d`ik djsa A

Hkonh;]
 [S-3]
SCHEDULE 'C'

DECLARATION

Tender for :
________________________

Name of Tenderer :
________________________

Specification No. and date of opening :

_________________
 In Consideration of the U.P. Power
Corporation Ltd., having treated the Tenderer to be
an eligible person whose tender may be
considered, the Tenderer hereby agree to the
condition that the proposal in response to the
above invitation shall not be withdrawn within six
months (or any extension
there of) from the date of opening of the tender,
also to the

(2)
condition that if thereafter the Tenderer does
withdraw his proposal within the said period, the
Earnest Money deposited by him may be forfeited
to the U.P. Power Corporation Ltd. and at the
descretion of the Purchaser, the purchaser may
debar the tenderer from tendering for minimum
period of one year reckoned from the date of
opening of the tender.

Signed this________day of_____________200____.

Place_____________Signed by_________________

Witness: Tenderer

Full Signature_________________________

Name________________________________

Designation___________________________

INDEMNITY BOND

This indemnity bond is executed

this_______________ the day of____________200 by
Sri
_______________________________S/O________________
__________________ R/O
_____________________________District______________
______ in favour of U.P. Sahkari Gram Vikas Bank
Ltd., Lucknow.

Where as the executant has served

as________________________________at
__________________________________________of this
Bank and retired from service
on________________________ . The executent has to
get the retiring benefit and other dues from the
Bank.

Where as I________________________ the

executant of this Bond agrees that if any dues of
whatever kind come to the knowledge of the Bank
upon me. I undertake and agree that I would be
responsible to make good the claim of the Bank
and I would be personally liable to pay of amount
due upon me.

(Noe this Deed Witnessth)

That in persuance of aforesaid bond retiring

benefits or any other dues, payable to me from the
Bank be paid to me. I hereby agree with the Bank
that I shall all times indemnity and keep harmless
the said Bank from all damages against the Bank
due to my negligence during my service period.

In witness whereof the executant has put his

signature on the day and year above mentioned.

(Executant)
WITNESSES:

1.____________

2.____________
 SPECIMEN AFFIDAVIT TO BE SUBMITTED BY
APPLICANTS AS PROOF OF DATE OF BIRTH

I Shail Kumari Srivastava W/O Sri Om

Prakash Lal presently residing at H.No. 173A,
Raidopur Kali Choura, Sadar, Distt.
Azamgarh, here by state as follows:
That I was born on First January
Nineteen Hundred Fifty Six (01.01.1956) at
Azamgarh, situated in the District of Azamgarh in
the state of Uttar Pradesh. I have no documentary
proof in the support of my place and date of birth.
I take oath and solemnly declare affirm
that the particulars furnished by me above are
correct and that I have not cancealed of
misrepresented any facts.

Place: Azamgarh Signature of

Applicant
Date: 22.01.2008

(SHAIL KUMARI
SRIVASTAVA)

Verified on this 22th day of January,

2008 that the contents of my ahove affidavit are
true and correct to the best of my knowledge and
belief and nothing in material has been cancealed
therefrom.

DEPONENT
 Attested (SHAIL KUMARI
SRIVASTAVA)

Signature and official seal of attesting authority.

AFFIDAVIT

(For Pre-qualification)

I...........................................S/o
Shri.............................................................
age..................years residing
at.........................................................................
(address) working as Proprietor/Managing
Partner/Director of M/s................................................
........................ having its registered office
at..................................................do hereby solemnly
affirm and declare on oath as under:
1- That I am competent to swear this affidavit
being Proprietor/one of the partners/ Director
M/s.................................................................................
2- That my firm
M/s.......................................................is a
proprietorship/ partnership firm /company
participating in tender for carrying out Handling &
Transportation work
at...................................................railhead centre.
3- That I hereby confirm and declare that none of
my/our/sister concern/ associate company
participating/submitting this tender.
4- That I hereby confirm and declare that my/our
firm/company M/s................
.................................and my/our firm/group/sister
concern associate company
Contd...2...
(2)
 have not been black listed/de-listed or put on
holiday in any Institutional agencies/Govt.
Deptt./Public Sector Undertaking in the last two
years.
5- That here is no Change in the Name & Style
Constitution and Status of the firm/company after
pre-qualification.
6- That I/We will open and maintain local
establishment at.............................. Rake
point/centre on award contract within stipulated time
given by N.F.L.
7- Details of sister concerns as on date is given
below;
Name of firm (Sister concern) Type of
business Details of association
1-
2-
8- That I further undertake that in case any of the
facts contained above and in our application is
found other wise or incorrect or false at any stage
my/our firm/company/group sister concerns
associate company shall stand debarred from the
present future tenders of the N.F.L.
(Signature of Proprietor/Managing
Partner/Director with Seal)
 DEPONENT
Verified
at.................................on.............................................t
hat the contents of para 1to 8 of this affidavit are true
and correct to best of my knowledgeand no part of
this is false and no ____________material has been
concealed or falsely stated therein
(Signature of Proprietor/Managing
Partner/Director with Seal)

DEPONENT

(Signature & Seal of Notary)

 SCHEDULE -C

DECLARATION

Tender invited by
:..............................................................
Tender for
:..............................................................
Name of Tenderer
:..............................................................
Specification No. and date of opening
:....................................

In consideration of U.P. Power Transmission

Corporation Ltd. having treated the tenderer to
be an eligible person whose tender may be
considered, the tenderer hereby agree to the
condition that the proposal in response to the
above invitation shall not be withdrawn within
six months (or any extension thereof) from the
date of opening of tender, also to the condition
that if thereafter the tenderer does withdraw
his proposal within the said period, the earnest
money deposited by him may be forfeited to
the UPPTCVL and at the descretion of
purchaser, the purchaser may debar the
tenderer from tendering for minimum period of
one year reckoned from the date of opening of
the tender.

Yours
faithfully

Place:..........................
Date :..........................
Siganture of the Tenderer
Witness:..........................
with seal & Date
Address :...................................................

FROM FOR HYPOTHECATION DEED (AGENT)

The Agreement made
at........................................this.................day
of...........................
200.............between THE LIFE INSURANCE
CORPORATION OF INDIA a Corporation established
by the Life insurance Corporation Act, 1956 and
having its Central Office
at................................................................................
.....................................Bombay
and ............................................................................
Zonal/Division/branch office
at................ .....................................(hereinafter
called "the Corporation" Which expression shall
unless repugnant to the context or meaning there of
be deemed to include its successors and assigns) of
the one part and Shri/Smt.
Kum ........................................ ..................... Son/
Wife/Daughter
of................................................................................
............ residing
at ..............................................................
(Hereinafter called" the
wherever the context or meaning shall so require or
permit) an agent appointed by the Corporation in
respect of Life Insurance business of the other part.
 WHEREAS
1- The Agent is appointed under the L.I.C. of India
(Agents) Rules. 1972 attached to
the..............................................................................
.................Branch of the Corporation
at................................. and requires a Motor car/
Scooter/ Motor cycle/Moped/for the proper
discharge of his/her duties and to.
secure the maximum amount of Life Insurance
Business from the territory under his/her charge
and to perform the other functions required of
him/her as such agent.

I.T.S. 18A
FORM NO. 16A
Certificate of deduction tax at source under Section
203 of the Income tax Act (1961)
"[For interest on securities dividends interest on time
deposits referred to in clauses (VII) and VIIA) of Sub-
Section (3) of section 194A, insurance commission
payments in respect of deposits under National
Savings Scheme payments on account of repurchase
of units by Mutual Fund or Unite Trust of India.
Commission remuneration or price on sale of lottery
tickets. Commission or brokerage. Income from units
referred to in section 196B"]
Name and TDS circle Name and Address of the
address of where person whom payment
person Annual made or in whose
Return under account is credited
 section 206
is to
delivered

TAX DEDUCTION A/C NO. Nature of PAN/GIR No. OF

THE DEDUCTOR payment THE PAY
PAN/GIR No. OF THE FOR THE PERIOD
DEDUCTOR
TO
DETAILS OF PAYMENT TAX DEDUCTION AND DEPOSIT OF
TAX INTO CENTRAL GOVERNMENT
Date of Amount Amount Rate Date&Ch Name of
payment paid of which allan No. Bank &
credit credited income deducte deposit Branch
(Rs.) tax d tax in to where
deducte Central Amount
d (Rs.) Governm Deposite
ent d to
Account Govt.
Account
Certified that a sum of Rs. (in words)
has been deducted at source and paid to the credit on
the Central Government as per details given above/

Place......................................... Signature of
person responsible for deduction of tax

Date.......................................... Full
Name..............................................................

Designation...................
........................................

As per Income Tax (6th Amendment) Rule, 1991.

 BILL/CASH MEMO

Received from

______________________________________ Rs.

_________________ (In words)

_______________________________

_____________________________________________

_______on account of

serialling/unserialling/wrappoing/searching/bun

dling/rebundling/keeping & bringing of post

paid L.C. Top up subscribers records & files for

the period from____________________to

________________ on contract fixed basis.

Name

Address:
-------------------------------------------------------------------------
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---------------------------
 INDEMNITY BOND

THIS INDEMNITY BOND IS executed on

this______________________________
by_______________________________________S/O,W/O
_______________________ R/O
___________________________________________________
_________________
(hereinafter called 'the Indemnifier) to secure and
indemnify Sahara India and M/S Sahara India
______________________________________ a company
duly formed and registered under the Company's
Act, 1956 having its principal place of business at
Sahara India Bhawan, 1, Kapoorthala Complex,
Alignaj, Lucknow (hereinafter called 'the
Indemnified Company").
AND WHEREAS "the Indemnifier: had
opened an account with the Indemnified Company"
at its Branch Office _____________________Account
No. ___________________ and had deposited a sum of
Rs. _____________________on dated
____________________.
AND WHEREAS the original pass
book/Fixed Deposit Certificate/Bond (hereinafter
called "the document") issued by "the Indemnified
Company" against the said account, is required to,
be returned and surrendered to "the Indemnified
Company " before the final settlement of the said
account and payments to be made thereunder.

(2)
 AND WHEREAS "the Indemnifier" has
declaired that " the document" issued against the
said account, has been lost and presently not
available in his custody or his/her nominee. "The
Indemnifier" has assured and undertaken that in
case "The Document" is subsequently traced out or
received by him/her, he/she will surrender the same
to "The Indemnified Company" and shall not use
"The said dcocument" for any other purpose
whatsoever without the consent in writing of "The
Indemnified Company" and/or make any further or
other claim on the basis of "The said document".
AND WHEREAS relying on this declaration
and assurances of "The Indemnifier" and in
consideration of this Indemnity Bond, "the
Indemnified company" has made settlement of the
Account and released the payment, in absence of
"the said document" on condition that if any third
party or person claims, pursues, contest or
otherwise demands any money out of the proceeds
of the aforesaid account, from "the Indemnified
Company" or any of its officers, employees or
agents etc. on the basis of the said document,
and/or otherwise "the Indemnifier" shall indemnify
and keep indemnified to the "Indemnified
Company" to the extent of all such claims and
demand including all its losses, costs, expenses etc.
in defending such demand or proceedings. "The
Indemnifier" also undertakes and assures that in
case of any such eventuality, he will promptly clear
and settle at his/her own cost all such claims and
demands and protect the interest of "the
Indemnified company" and its officers, employees,
agents, etc. against any claim, demand, legal
proceeding, loss of good will, discredit reputation or
otherwise cost which are made against "the
Indemnified Company".
AND WHEREAS the Indemnifier has agreed
with the Indemnified Company that in case of any
dispute, claim, or controversy arising out or in
connection to the settlement of the said Account or
arising there under the dispute shall be adjudicated
by arbitration and Indemnified Company shall refer
the dispute to a sole arbitrator for adjudication
under the provisions of the India Arbitration and
Conciliation Act, 1996 and the Award passed by the
sole arbitrator shall be final and binding upon the
parties. The venue of the Arbitration shall be at
Lucknow (U.P.) and the language of the Arbitration
shall be English.
 (3)

AND WHEREAS, the stamp duty chargeable

on this instrument has been borne and paid by "the
Indemnifier". The Indemnifier" has undertaken to
pay the deficit stamp duty, if levied on this
instrument at any time after its execution and also
assures for not to make any objection in this regard,
if this instrument is produced before any court or
authority for its enforcement.
I, "the Indemnifier" also certify that the
contents of this instruments are voluntarily agreed
and executed by me after I have read and
understood the contents of the same, in my own
language, while signing this document.

Executed and signed on this....................day

of........................Month, 20

Place: Azamgarh.

Signature for & on behalf of

Signature of "the Indemnifier"
"the Indemnified Company"
Name
 S/O,D/O,W/O

R/O

NAME & ADDRESS OF THE WITNESSES:

SIGNATURE OF THE WITNESSES

1.

2.

INDEMNITY BOND
(FOR ISSUE OF DUPLICATE SAHARA MULTI
PLUS, SAHARA UNIQUE RECEIPT ON NON
JUDICAL STAMP PAPER OF RS. 100/-)

To,
 SAHARA INDIA COMMERCIAL
CORPORATION CORPORATION LTD.
Sahara India Bhawan,
1, Kapoorthala Complex
Aliganj, Lucknow- 226024

Dear Sirs,
I/We, Mr./Mrs./Ms.
___________________________________
S/O,W/O ____________________________R/O
________________________
_______________________________________________
__have tendered advance under Sahara Multi
Plus, Sahara Unique Scheme (strike-off
whichever not applicable ) as per the following
details:

RECEIPT NO. AMOUNT

(2)

I/We, declare and accept that the

above stated Sahara Multi Pluc, Sahara Unique
Receipt(s) of the company has/have been
lost/misplaced and the same is/are not
traceable by me. I further declare that I have
not mortgaged, pledged to any one or
deposited any where the original Abode
Bond/Nirman Bond certificate(s) by way of
security or otherwise or transferred or sold to
any person the said Abode Bond/Nirman Bond. I
agree and promise to return forthwith to the
company the said original Abode Bond/Nirman
Bond certificate(s) if found in future, for its
cancellation.
 I/We, the above named person(s)
hereby state and confirm that in consideration
of the company issuing such duplicate
certificate(s) of Abode Bond/Nirman Bond
certificate(s) on our request. I/We undertake to
indemnify the company at all times and from
time to time save, defend, and keep the
company harmless including its successor(s)
assignee(s) and the director(s) share holders,
officers, workers etc., thereof and their
respective heir(s) executor(s) administrator(s),
each of their estates and effects, harmless from
and against all actions, costs, suits
proceedings, claims and demands whatsoever
on account of the said Abode Bond/Nirman
Bond or any of them for loss or non production
of certificate(s) thereof, on the part of any
person(s) whatsoever and against all damages,
costs, charges, expenses and sum of money
incurred in respect of or otherwise, for any
misuse/claims.
I/We, further declare and agree by
these presents that in the event of my/our
failure to compensate or indemnify the
company in any action/suits and proceedings,
which the company may face for having issued
the duplicate Abode Bond/Nirman ond
Certificate(s) at my/our request, the company
shall have a lien on all the Bonds which I/We
am/are now holding or I/We may hold thereafter
including the interest accured or payable on the
said Bonds on other movable/immovable
property owned possessed singly/jointly by
me/us.
We, the sureties whose names and
addresses are given hereunder promise and
undertake to return and redeliver such original
Certificate(s) of Abode Bond/Nirman Bond, after
release of duplicate Abode Bond/Nirman Bond
Certificate(s) without such demand to produce,
and return to the company, the

(3)

original bonds certificate(s) when found or

traced and to take all corrective action, suits
and proceedings at our own cost as to defend
and keep harmless the company for the
recovery there of in case the above named
Bond holder(s) fails to comply, with the above
statement, We further declare that, we shall
indemnify the company and its successors,
assignees, administrators etc., against all the
damages, costs, charges, expenses etc.,
incurred or to be incurred arising in whatsoever
nature by the company in relation to above
Abode Bond/Nirman Bond holder(s).
If any dispute arises among the parties
to this agreement that dispute shall be referred
to Sole Arbitrator appointed by the company
whose Award shall be final and binding on the
parties. Venue of arbitration shall be at
Lucknow.
Signature of Abode Bond/Nirman Bond
Holder(s).

(1) Full Name________________________ (2) Full

Name____________________

Address ___________________________ Address

________________________
__________________________________
______________________________
(Signature of Surety(ies)

(1) Full Name________________________ (2) Full

Name____________________
Father's Name_______________________ Father's
Name__________________
Address ___________________________ Address
________________________
__________________________________
______________________________
Signature of Witnesses
(1) Full Name________________________ (2) Full
Name____________________

Address ___________________________ Address

________________________
__________________________________
______________________________
Dated____________________ day of
_______________20________

Place: Collectrate Court, Azamgarh

 INDEMNITY BOND

This bond of indemnity is excuted

by..........................................................(Name of
the Account holder) aged about years NDN
of.................................. .........................resident
of ...........................................................................
(herein after referred as Induemnifier) which
expression shall, unless repugnant to the context
or meaning thero of, include its successors,
administators, representative and assignees in
favour
of ................................ .................................
(name of the company)herecinafter referred to as
the 'Indemnified' which expression shall unless
repugnangt to the context of meaning there of,
include its successors and assignees witnesses us
to.

Whereas the indemnifier had opend an individual

account/joint account bearing
number......................................under.....................
..............(name of the scheme) on......................
(date of opening) for denomination of
Rs............................to be deposited
on.............................(mode of deposit) basis.

Whereas the indeminifier was issued by the

indemnified a passbook bearing
no...........................against the account opend
which was to be compulsorily submitted before
the indemnified at the time of claiming maturity
payment.

(2)

And whereas the indemnifire have lost or

mislaid/misplaced the pass book issued by he
indemnified and which is now is not traceable.
Now therefore the above named indemnifire has
approached the indemnified to make the maturity
payment on .............../................../.................(date
of maturity) against the account
number........................................(a/c number)
under.......................(name of the scheme), to
which the indemnified has agreed.

In consideration of the indemnified having made

and /or agreed to make the maturity payment,
I/we............................................(name of the
executor) hereunder for mayself/ourselves,
my/our heirs, executors, administrators and
assigns do hereby jointly and severally covenent
with the indemnified, its successors and assigns
and irrevocably agree and undertake at all times
to save, defend and to indemnify and keep
indemnified the..............................................
(name of the company), its successors and
assigns its estate and effects, and its directors,
manager, secretary and shareholders and their
heirs, executors and assigns from and against all
actions, suits proceedings, accounts, claims and
demands whatsoever for or on account of the said
shares or dividends or any part thereof or
otherwise in connection with the same, and from
and against all losses, costs, claims, actions,
demands, risks, charges, expenses, damages and
losses arising in any manner howsoever.

I/We................................(name of the executor)

hereby agree and undertake to uncondunt return
and deliver the said pass book (in original) to the
indemnified the same is found at there date.
In witness whereof I/We the applicants (s)herein
has/have signed and set my/our hands on
this.................day of.................200..........

(3)

Name & Address of Signature of the

the Account Holder Account Holder (s)
(s)
1. -
2. -
 Name & Address of Signature of the
the Witnesses Witnesses
1. -
2. -

Place :................................
Date :.................................

NOTES :
1. Indeminity Bond should be on Non Judicial
Stamp Paper of Rs. 100/-,witnessed by two
independent persons.
2. Please fill up the correct details as applicable.
3. Indemnity Bond should be duly attested by a
Notary Public.
4. The spouse of he shareholder (s) cannot be a
witness.
 ¼2½
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leuqns'krh½ o izfrHkw ds uke
----------------------------------------------------------------------
----------------------------------------------------------------------
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Annexure-III
Indemnity Letter
for payment of balance in account of deceased
eepositors
(To be used for cases other than nomination or is
a joint account without survivorship clause)

Name:________________________
Address: ________________________
______________
____________
Date:___________________________
To
Bank of India,
Azamgarh Banch.
Dear Sirs,
Re. Payment balance of
Rs.________________in the account of
Mr./Mrs./Miss.________________________
__________(Deceased).

Mr/Mrs./Miss____________________________
_____________has the Current Account
No.___________________Savings Bank Account No.
__________________
Fixed/Short/Monthly Income Certificate/Double
Benefit Deposit Account no. ______________
Recurring Deposit Account No.
________________________with your Bank.
2.

Mr./Mrs./Miss__________________________________ha
d expired on________________ at
_____________leaving at the time of his/her death
the credit balance(s) in his/her respective
account(s) as under:
(a) Current Account no. :
Rs.______________________
(b) Saving Bank Account no. :
Rs.______________________
(c) Fixed/Short/Monthly Income
Certificate/Double Benefit Deposit
Account No. :
Rs.______________________
(d) Recurring Deposit Account No. :
Rs.______________________
:
____________________________

Total: :
Rs.______________________
___________________
________
1. KNPWN ALL MEN THE THESE PRESENTS THAT
we the
 Article of agreement amde at Azamgarh
this 10th Oct. day of 2009 between Life
Insurance Corporation of India, a body corporate
constituted and established by the Life Insurance
Corporation Act, 1956 (Act 31 of 1956) and
having its Central Office at Yogeshema, Mumbai
& its Branch Office at Azamgarh called employer
(which expression shall include its successors
and assignees where ever context or meaning
shall so require or permit) of the one part and
Shri Sunil Kumar Gupta S/O Late Shri Mohan Lal
Gupta residence 145/A Raidopur Kali Choura,
Azamgarh carrying on business in proprietor
under the name and style of M/S Madhesia
Electro Corporation (hereinafter called the
contractor) of the other part.

Where as employer is desirous of having

one No. new Kirloskar make 10 KVA single phase
DG set and one No. new Kirloskar make 15 KVA
single DG set sound less & smoke less of
approved make Canopies on hire basis at Branch
Office-2 Azamgarh, which shall be operated as
per following details:

Contd.....2

(2)

1. The DG set shall have to run in the event of

load shedding/power cut/ break down/Erratic
power supply from supply co. on all working
days as follows:

Monday to Friday : 9.30 AM to 5.30PM

 Saturday : 9.30 AM to 2.00 PM

2. Monthly hiring charges & Over Time are as

follows:

(a) Monthly hiring for 15 KVA DG set-

Kirloskar make
(smokeless & soundless) @Rs.
17,000/- per month

(b) Monthly hiring for 10 KVA DG set-

Kirloskar make
(smokeless & soundless) @Rs.
13,800/- per month

(c) Over Time charges for 15 KVA DG Set

running beyond working hours including
Sundary & holidays. @Rs. 225/-
per hour
Over Time charges for 10 KVA DG Set
running beyond working hours including
Sundary & holidays. @Rs. 175/-
per hour

(3)

(d) Waiting Charges of operator when DG

set
is not operated beyond working hours.
@Rs. 45/- per hour

3. The contract shall be valid initially for 03

years commencing from date of installation
and commissioning of DG set which may be
extended further for another 03 years on
mutual consent. If the performance of
running sets is not found satisfactory at any time
during contract period, LIC of India reserves
the rights to terminate the contract by serving
one calendar months notice.

4. In case of break down in generator supply,

deduction shall be made based on OT rate for
running of DG set beyond normal hours & if the
same is not restored within 24 hours corporation
will be free to hire another DG set from the
market at your risk & cost limited to double the
amount quoted by the contractor.

5. Increase and decrease in the cost of fuel

may be considered as per notification of
rates by Govt. of India. Average fuel
consumption of DG set shall be taken from
the standared fuel consumption chart of DG
set manufacturer.

6. A log book shall be maintained for recording

the daily running of DG set including Over
Time which should be signed by authorized
 representative of LIC.

7. You will have to submit the bill in triplicate in

the first eek of the following months
alongwith zerox copy of Log book & original Log
book for certification & settlement of bill.

8. If required, you have to obtain approval from

pollution control board & directorate of
electrical safety without any extra cost of LICI.
Nothing extra shall be paid on this account.

(4)

9. You have to obtain policies to cover TP, Fire

& WC insurance to cover of adequate amount
which shall remain in force till the contract
period & extension if granted. No payment shall
be released, if the insurance lapses during
contact period.

10. Basic diesel price is Rs. 32.44 (Rs. Thirty two

& paise forty four only) prevailing at the time
of submission of tender.

11. The contract comprises:

i) Acceptance letter dt. 18.08.2009

 ii) Discussion with store committee on
08.08.2009.

12. Essential electrical load such as UPS, fans,

lights/AC (One No.), Water
Cooler (one No.) shall be connected to DG
set.

Sig. of Contractor Sign. of

SR./Branch Manager
with date & seal Date:...................
(for & behalf of LIC of
India

Witness: Witness:

1.____________________ 1.____________________

2.____________________ 2.____________________
 'kiFk & i=

le{k %& Jheku~ 'kk[kk odZj egksn;]

lgkjk bf.M;k 'kk[kk dk;kZy;
fl/kkjh] vktex<+A

eSa-----------------------------------------------------------------
--------
iq=@iRuh---------------------------------------------------------------
--
fuoklh--------------------------------------------------------------------
---------------------------------------------vktex<+ l'kiFk liFk
djrk@djrh gwW fd&
1& ;gfd esjs -----------------------------------}kjk
fnukad----------------------------------
dks------------------------------------------- ;kstuk ds vUrxZr
[kkrk@dUVªksy
la[;k&-------------------------------------------------[kksyk x;k
vkSj vkt fnukad-----------------------------------rd
#i;s-----------------------------------------vfxze tek fd;k x;k
gS] ftlds fy, izek.k i=@ikl cqd
la0-----------------------------------------
fnukad---------------------------- dks fuxZr fd;k x;k FkkA
2& ;g fd mDr dUVªksy la0------------------------------- ds
vUrxZr vkids 'kk[kk dk;kZy; }kjk fuxZr izek.k i=@ikl
cqd la0----------------------------------
fnukad-------------------------------la okLro esa [kks x;k
gS@u"V gks x;k gS ,oa miyC/k ugha gSA

¼2½
3& ;gfd mDr lUnHkZ esa
eS---------------------------------------mDr [kks;s gq;s izek.k
i=@ikl cqd ds cnys MqIyhdsV izek.k i=@ikl cqd
fuxZr djus gsrq fuosnu djrk gwW vkSj og opu ns jgk
gwW fd ;fn Hkfo"; esa mDr izek.k i=@ikl cqd eq>s ewy
#i esa izkIr gks tkrk gS] rks eSa mls vkids 'kk[kk
dk;kZy; dks vo'; lqiqnZ dj nwWxkA
4& ;gfd lkFk gh og Hkh opu ns jgk gwW fd ;fn izek.k
i=@ikl cqd ds vFkok vU; fdlh vk/kkj ij esjs fdlh
mRrjkf/kdkjh vFkok ukfeuh }kjk fdlh Hkh izdkj dk
dksbZ ekax i=] ifjokn ;k nkok is'k ugha fd;k tk;sxkA
5& ;gfd okn [kks;s gq, izek.k i=@ikl cqd ds vk/kkj ij
fdlh Hkh O;fDr }kjk fdlh izdkj dk dksbZ Dyse] ifjokn]
nkok vFkok okn laLFkk ds fo#) nk;j fd;k tkrk gS rks
eSa ;g cpu nsrk gwW fd eSa laLFkk dks lHkh izdkj ls
lg;ksx d#axk ,oa laLFkk dks lHkh izdkj dh gkfu {kfr]
[kpsZ O;; ftlesa odhy Qhl 'kkfey gksxh] dks {kfriwfrZ
ogu ds lkFk&lkFk laLFkk dks lHkh ifjfLFkfr;ksa esa gkfu
ls eqDr j[kWwxkA
6& ;gfd ;fn esjs }kjk dh x;h dksbZ mijksDr ?kks"k.kk
fdlh Hkh lUnHkZ esa xyr ikbZ tkrh gS vFkok fookn
gksrk gS rks eSa izek.k i=@ikl cqd esa mfYyf[kr leLr
tek jkf'ku; gtsZ [kpsZ ,oa O;; ds dEiuh esa tek dj
nwWxk rFkk bl lEcU/k esa lHkh izdkj dh dkuwuh
dk;Zokgh bR;kfn ds fy;s ftEesnkj jgwWxkA

'kiFkdrkZ dk uke&
gLrk{kj&

lR;kiu

eSa mijksDr 'kiFkh og lR;kfir djrh gwW fd

mijksDr iSjk 1 ls 6 rd ds dFku esjs tkudkjh esa lR; ,oa
lgh gS rFkk dksbZ rF; fNik;k ugha x;k gSA

'kiFkdrkZ dk uke& gLrk{kj&

fnukad&
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fo"k;& lgkjk Lo.kZ ;kstuk@jtr ;kstuk@flYoj bZ;j ykHk

ds vUrxZr tkjh izek.k i=@ikl cqd dh f}rh; izfrfyfi
tkjh djus gsrq&
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
&&&&&&&&&&&&&&
le{k %& es0 lgkjk bf.M;k dke'khZ;y dkjiksjs'ku fy0
lgkjk bf.M;k Hkou] diwjFkyk dkEiysDl
1 diwjFkyk dkEiysDl] vyhxat+] y[kuÅ&
226024A
egksn;]
eSa---------------------------------------------
iq=-------------------------------------
fuoklh--------------------------------------------------------------------
---------------------------------------------------vktex<+ ds
fuEufyf[kr fooj.k ds vuqlkj
lgkjk-----------------------------------------------------------@ikl
cqd ds vUrxZr lgkjk bf.M;k dkef'kZ;y dkjiksjs'ku fy0 dh
vpy lEifRr vkSj@;k lgkjk bf.M;k dkef'kZ;y dkjiksjs'ku fy0
vkSj@;k bldh O;kolkf;d lg;ksfx;ksa ds mRikn Ø; djus
vkSj@;k lgkjk bf.M;k dkef'kZ;y dkiksZjs'ku fy0 vkSj@;k
bldh lsok;sa izkIr djus gsrq vfxze /kujkf'k dk Hkqxrku
fd;k gS ftldk fooj.k fuEu gS %&
dUVªksy la0 jlhn la0 vfxze /kujkf'k izek.k
i=@iklcqd la0

¼2½
eSa ?kks"k.kk djrk gwW fd mijksDr fooj.k ds lgkjk flYoj
bZ;j ykHk ;kstuk ds izek.k i=@ikl cqd okLro esa [kks
x;s gS vkSj esjs }kjk [kks;s ugha tk lds gS vkSj eSa
vkxs ?kks"k.kk djrk gwW fd eSaus ewy lgkjk flYoj bZ;j
ykHk ;kstuk ds izek.k i=@ikl cqd dks fdlh #i esa ns u
rks fdlh ls fxjoh vFkok ca/kd j[kk gS vFkok dgha tek
fd;k gS vkSj u gh mDr lgkjk flYoj bZ;j ykHk ;kstuk izek.k
i=@ikl cqd dks fdlh Hkh izdkj ls gLrkukUrfjr fd;k gS
vFkok cspk gS vkSj Hkfo"; esa lgkjk flYoj bZ;j ykHk
;kstuk izek.k i=@ikl cqd ds ik;s tkus dh fLFkfr esa bl rF;
ls lger gwW vkSj opu nsrk gwW fd eSa rRdky ewy lgkjk
flYoj bZ;j ykHk izek.k i=@ikl cqd dks jn~n djus ds
okLrs dEiuh dks ykSVk nwWxkA
eSa mijksDr O;fDr ,rn~}kjk Li"V djrk gwW fd dEiuh
}kjk ,sls lgkjk flYoj bZ;j ykHk izek.k i=@ikl cqd dh nwljh
izfr tkjh djus dh ,ot esa eSa dEiuh dk fdlh Hkh le; {kfr
iwfrZ djus vkSj dHkh Hkh mDr lgkjk flYoj bZ;j ykHk
izek.k i=@ikl cqd ds ckor vFkok muesa ls fdlh ds Hkh
ckor vFkok lHkh }kjk muds izek.k i=ksa dks izLrqr djus
dh rFkk Hkqxrku izkIr djus dh fLFkfr esa dEiuh mlds
mRrjkf/kdkjh;ks ¼;ks½ vkSj mlds funs'kd ¼dks½
'ks;j /kkjdksa] vf/kdkfj;ksa] dk;ZdrkZvksa mu lHkh ds
vius&vius okfjl ¼3½
¼lks½] fu"ikndksa] iz'kkldksa vkSj mu lHkh ds
viuh&viuh lEinkvksa] pht okLrksa dks lHkh izdkj ls
vuq;kstuksa ykxrksa] O;;ksa] oknksa] dk;Zokfg;ksa]
nkoksa rFkk ekaxks ls vkSj mlds fo#) fdlh Hkh izdkj dh
uqdlkuks ls izfrj{kk djus rFkk vgkfudj j[kus vkSj mlds
ckor vFkok fdlh vU; ds ckor mixr /ku dh jkf'k;ksa]
{kfr;ksa] ykxrksa] izHkkjksa] [kpksZ ls cpkus dk cpr
nsrk gwWA
eSa vkxs ?kks"k.kk djrk gwW vkSj iw.kZ #i ls lger
gwW fd dEiuh ds lkFk fdlh Hkh izdkj dks
dk;Zokgh@oknksa rFkk dk;Zokfg;ksa ftldk lkeuk dEiuh
dks esjs vuqjks/k ij mDr lgkjk flYoj bZ;j ykHk izek.k
i=@ikl cqd dh f}rh; izfr tkjh djus ds dkj.k djuk iM+ ldrk
gS] dk esjs }kjk izfrdj u dj ikus dh fLFkfr esa esjs }kjk
bl le; /kkj.k fd;s gq, vFkok esjs }kjk rRi'pkr /kkj.k fd;s
tkus okys mu lHkh lgkjk flYoj bZ;j ykHk izek.k i=@ikl
cqd vkSj mDr lgkjk flYoj bZ;j ykHk izek.k i=@ikl cqd ij
ns; C;kt lfgr ewy /ku ,oa gekjh py ,o vpy lEifRr ij
dEiuh /kkj.kkf/kdkj izkIr dj ldrh gSA
ge tekurnkj ftuds uke vkSj irs uhps fn;s x;s gSA
lgkjk flYoj bZ;j ykHk izek.k i=@ikl cqd dks nwljs izfr
tkjh fd;s tkus ds i'pkr izek.k i=@ikl cqd dh ewy izfr;ka
<w<+us ij vFkok fdlh Hkh izdkj ik;s tkus ij mudh ewy
izfr;ka dEiuh dks ykSVkus vkSj mijksDr ikl cqd /kkjd }
kjk mi;qZDr ?kksf"kr dFku ds vuqikyu esa okil gksus dh
fLFkfr esa blds }kjk gksus okyh lHkh izdkj dh {kfr
iwfrZ] uqdlku] [kpkZ vkfn dh vko';drkuqlkj olwyh ds
fy;s dEiuh }kjk ekaxs tkus ij lHkh vuq;kstuksa] nkoksa
rFkk dk;Zokfg;ksa dks vius [kpZ ij ogu djus dh 'kiFk
ysrs gSA
ge vkxs ?kks"k.k djrs gS fd blds fy, vkSj vkosnd dh
vksj ls mDr lgkjk flYoj bZ;j ykHk izek.k i=@ikl cqd ds
lEcU/k esa gq;s lHkh izdkj ds uqdlkuksa ykxrksa]
izHkkjksa] O;;ksa vkfn ds izfr dEiuh dh {kfriwfrZ dj
nsaxsA
bl ck.M ds i{kdkjksa ds e/; bl lafonk dks ysdj fdlh
Hkh izdkj dk fookn gksus ij og fookn dEiuh }kjk
fu;qDr ,d ek= vkfcZVªsVj dks lUnfHkZr fd;k tk;sxk ftldk
,okMZ vfUre gksxkA fookpu dk LFkku y[kuÅ gksxkA

vkosnd dk iwjk uke& gLrk{kj

irk&

tekurnkjksa ds gLrk{kj
1& iwjk uke& 2& iwjk uke&
firk dk uke& firk dk uke&
irk& irk&
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1& iwjk uke& 2& iwjk uke&
firk dk uke& firk dk uke&
irk& irk&

fnukad&
LFkku&
 mRrj izns'k ds vU; fiNM+s oxZ ds fy, tkfr izek.k&i=
¼izk:i&1½

izekf.kr fd;k tkrk gS fd Jh@Jherh@dqekjh

--------------------------------------------------------------
lqiq=@lqiq=h---------------------------------------------------------
--- fuoklh----------------------------------------
rglhy---------------------------------
uxj------------------------------------------------------------
ftyk---------------------------------------- mRrj izns'k jkT; dh
--------------------------- fiNM+h tkfr ds O;fDr gSa A ;g tkfr
m0iz0 yksd lsok ¼vuqlwfpr tkfr;ksa] vuqlwfpr
tutkfr;ksa vkSj vU; fiNM+s oxksZa ds fy;s vkj{k.k½
vf/kfu;e] 1994 ¼;Fkkla'kksf/kr½ dh vuqlwph&,d ds
vUrxZr ekU;rk izkIr gS A
;g Hkh izekf.kr fd;k tkrk gS fd
Jh@Jherh@dqekjh
-------------------------------------------------------iwoksZDr
vf/kfu;e] 1994 ¼;Fkkla'kksf/kr½ dh vuqlwph&nks tSlk
fd m0iz0 yksd lsok ¼vuqlwfpr tkfr;ksa] vuqlwfpr
tutkfr;ksa vkSj fiNM+s oxksZa ds fy;s vkj{k.k½
¼la'kks/ku½ vf/kfu;e] 2001 }kjk izfrLFkkfir fd;k x;k
gS ,oa tks m0iz0 yksd lsok ¼vuqlwfpr tkfr;ksa]
vuqlwfpr tutkfr;ksa vkSj vU; fiNM+s oxksZa ds fy;s
vkj{k.k½ ¼la'kks/ku½ vfu;e] 2002 }kjk la'kksf/kr dh
x;h gS] ls vkPNkWafnr ugha gS A buds ekrk&firk dh
fujarj rhu o"kZ dh vof/k ds fy;s ldy okf"kZd vk; ikWap
yk[k :i;s ;k blls vf/kd ugha gS rFkk buds ikl /kudj
vf/kfu;e] 1957 esa ;Fkk fofgr NwV lhek ls vf/kd lEifRr
Hkh ugha gS A
Jh@Jherh@dqekjh
------------------------------------------------------------
rFkk@vFkok mudk ifjokj mRrj izns'k ds
xzke------------------------------------------------------------
rglhy----------------------------------------
uxj------------------------------
ftyk------------------------------------------------------------ls
lkekU;r;k jgrk gS A

LFkku%--------------------------------
gLrk{kj% -----------------------------------------------------
fnukad%------------------------------ iwjk
uke ----------------------------------------------------
eqgj------------------------------------ in
uke -----------------------------------------------------
ftykf/kdkjh@vfrfjDr ftykf/kdkjh@flVh eftLVªsV@ijxuk
eftLVªsV@rglhynkj

¼2½
ml {kfr dh iwfrZ djsaxs tks fuxe mlds
mRrjkf/kdkfj;ksa ,oa leuqnsss'kfr;ksa ds fo:) fdUgh
O;fDr@O;fDr;ksa ds }kjk ewy ikfylh la[;k
-------------------------------------------ds nLrkost ij dCtk gksus
ds dkj.k vFkok mlesa fdlh mYys[k }kjk gdnkj gksus ds
dkj.k mRiUu gksaxsA
mijksDr dh lk{kh esa mDr ¼cheknkj]
leuqns'krh½ o izfrHkw ds uke
-----------------------------------------------------------------------------
-----------------------------------------------------------------------------
-----------------------------------------------------------------------------
-----------------------------------------------------------------------------
----
us vkt LFkku ----------------------------------------------- esa
fnukad ---------------------------
ekg------------------------------------------------
-------------------------------------------------- 200-------------------
dks gLrk{kj fd;sA
vUr% cf.kZr O;fDr;ksa }kjk gLrk{kfjr o izLrqr
1& ---------------------------------------------- 1
-------------------------------------------------
¼cheknkj dk uke½ ¼cheknkj ds
gLrk{kj½
2& -------------------------------------------------
2& ----------------------------------------------------
¼leuqns'khrh dk uke½
¼leuqns'kfr ds gLrk{kj½
-------------------------------------------------
3&-------------------------------------------------
¼izfrHkw dk uke½ ¼izfrHkw ls
gLrk{kj½
O;olk;
-----------------------------------------------
irk
-----------------------------------------------------
bu lkf{k;ksa dh mifLFkfr esa %
1& lk{kh % 2& lk{kh %
gLrk{kj ------------------------------------------
gLrk{kj ------------------------------------------
iwjk uke ----------------------------------------
iwjk uke ----------------------------------------
O;olk; -----------------------------------------
O;olk; -----------------------------------------
irk ------------------------------------------------
irk ------------------------------------------------
3& lk{kh %
gLrk{kj ------------------------------------------
 iwjk uke ----------------------------------------
O;olk; -----------------------------------------
irk ------------------------------------------------

LEASE DEED
THIS INDENTURE MADE THE
..........Day of..............Two Thousand and two
BETWEEN
Sri................................................................s/o
Shri.................................................................................
........................................................................................
........................................................................................
...............................r/o
of
........................................................................................
.................................................
........................................................................................
.................................................
................................................(hereinafter referred to
as 'the lessor(s) which expression shall where the
context so admits includes him/them and his/their
heirs executors, administrators, representative
successors and assigns) of the one part and THE
STATE NBANK OF INDIA, constituted under the State
BANK of India Act 1955 and having one of the Local
Head Offices at Moti Mahal Marg, Hazratganj,
Lucknow, and a branch at.........................................
(hereinafter referred to as 'The Bank' which expression
where the context so admits shall include its
successors and assigns) of the other part WITNESSETH
that in consideration of the rent hereinafter reseved
and the covenants and agreements hereinafter
contained and on the part of the Bank to be observed
and performed, the Lessor(s) hereby demises/demise
and lease unto the Bank all that messuage or
tenement of the ground floor of the building,
situated..................................., and belonging to the
Lessor(s) containing an area of......................Sq. feet
on the ground floor a little more or less, more
particularly described in the schedule appended with
all rights, easements liberties, appendages and
appurtenances there unto belonging (hereinafter
referred to as the demised premises) to HAVE and TO
HOLD the demised premises unto the bank for a term
of 10 (Ten) years to be computed from
the.......................................(date) and with the option
to Bank to renew the leases for further two terms not
exceeding five years each subject to the maximum.

Page 1 of 6

AFFIDAVIT

I, _____________________________(Name of the
authorized person) S/o Shri
_____________________________and
_____________________________of
the_______________________________________________( Na
me of tbhe College/ Institution / trust/ Socity Etc.
_____Year Resident of Village

_______________________________________________am the
authorized signatory of the application made to the
Regional Committee of theNational Council for the
application made to Bhopal/ Bhuwaneshwer/ Jaipur/
Bangalore seeking grant of recoginition / permission
for counducting a course in Teacher education
titled ______________with intake/additional intake of
__________ Unit.

2. That the
_____________________________________________________

_____________________Society/Trust/Insitution/College
(strike out whichever is not applicable) is in
possession of land as per the following description.

2.1 Total Area of the land (in Sqr. Mts.)

2.2 Address:

Plot No. :
Khasra No. :
Village/Town/City: :
District: :
State: :

Bounded by: :
North :
South :
East :
West: :
 (2)

Registered in the office of

_______________________________________
on___________________.
3. That the land is on ownership basis/lease from
Govt. for a minimum period of
________________________years (in figures and
words) Strike out whichever is not applicable.
4. That the land is free from all encumbrances.
5. That the land is exclusively meant for running the
educational institution and the permises on of the
Competent Authority to this effect has been obtained
vide letter
No._____________________dated__________________and a
copy thereof is enclosed.
6. That the said premises shall not be used for
running any educational activity/institution other
than the teacher education programme for which
recognition is being sought.
7. That the copy of the affidavit shall be displayed
on the website of the Institution for general public.
8. I do hereby swear that my declaration under
Para's (1) to (6) are true and correct and that it
conceals nothing and that no part of this is false. In
case the contents of affidavit are found to be
incorrect or false. I shall be liable for action under the
relevant provision of the Indian Penal Code and other
relevant laws.

Signature__________________
________
Name of the
Applicant_________________
Address____________________
_______
___________________________
_______
 ___________________________
_______

Tel :______________________
__
E-mail address:
_________________
Website address:
________________
Place:_________________
Date: _________________

UNDERTAKING
 That I have read and understood the contents of
the application and the same are true and the same
are true and correct the basis of my personal
knowledge and on the basis of records of the
institution.
In connection with my/our application for grant of
recognition/permission of
________________________________________(Name of the
Institution) to conduct
_________________course with
_______________take/additional intake, and hereby
undertake to comply with the following:
(i) That infrastructural, instructional and other
facilities has been/shall be provided as per the
NCTE norms, standards and guidelines prescribed from
time to time.
(ii) That admission to the Course will be made only
after recognition is granted by the concerned Regional
Committee of the NCTE and affiliation is granted by
the concerned University/Affiliating Body.
(iii) That admission of students, satisfying the
eligibility conditions will be made either on the basis
of marks obtained in the qualifying examination or in
the entrance examination conducted by the State
Govt./University as per its policy.
(iv) That there shall be reservation of seats for
sC/ST/OBC/other categories etc. as per the Policy of
State Govt.
(v) That the supporting and other staff will be
appointed as per the guidlines of the State
Govt./the affiliating University.
(vi) That the tuition and other fees will be charged at
rates prescribed by the concerned state
Govt./affiliating University.
(vii) That the academic and other staff of the
institution (including part time staff) shall be paid
such salary as may be prescribed by the concerned
State Govt. University from time to time.
(viii)That the Management shall discharge the
statutory obligations relating to provident fund
pension gratuity etc. in respect of all its employees.
(ix) That the Management will make adequate funds
available for providing satisfactory facilities and
for proper programme implementation.

(2)

(x) That the accounts of the institution will be

properly maintained and audited annually by the
audit authorities or a Chartered Accountant and will be
open for inspection.
(xi) That the Management will strictly follow all
conditions and norms prescribed by NCTE from
time to time, conduct the programme in all
earnestness, and submit it self to inspection by the
NCTE.
(xii) In the event of non compliance by the
_______________________________
(Name of the Society/Trustee/College/Institution
etc.) with regard to the norms and standards and any
other condition laid down/prescribed by the NCTE from
time to time, the NCTE or a body or a person
authorized by it will be free to take all necessary
measures for effecting withdrawal of its recognition or
permission, without consideration of any other issue,
and that all liabilities arising out of such a withdrawal
would solely be that of the Institution/Management.
(xiii)That the Management will not cause or allow
discontinuation of the Course in any year or
for any batch after grant of recognition, and that
where compelled to do so, it will seek the
concurrence of NCTE for discontinuation on the
completion of the year/batch.
(xiv) The (College/Institution) by virtue of the
approval given by the NCTE shall not automatically
become claimant of any financial grant or assistance
from the Central or State Govt. or support from
the NCTE.

Signature of the authorized Designated authority

alongwith his/her official position and office seal.)

Place:______________
Date_______________ NAME IN
BLOCK LETTERS
 lgkjk bf.M;k dkef'kZ;y dkiksZjs'ku fyfeVsM
}kjk lgkjk bf.M;k 'kk[kk------------------------------------

c;ku gYQh
feutkfuc-----------------------------------------------------------------
-------------------------------------gLc tSy gSA

1- ;gfd eSa cgyQ c;ku djrk@djrh gwW fd esjk

uke---------------------------------------------------------------------

iq=@iq=h@iRuh-----------------------------------------------------
-----
fuoklh--------------------------------------------------------------------
--------------- Fkkuk------------------------------------------------
ftyk---------------------------------------- dk fuoklh gwWA
2- ;gfd cgyQ c;ku djrk@djrh gwW fd ge izkFkhZ
¼'kiFkdrkZ½ dk vkids 'kk[kk esa dwiu
la[;k---------------------------------------fjlhIV
la0-----------------------------------
fnukad-------------------------------dks tks eqcfyx

#0------------------------------------------------------------------------
--------------dks ge 'kiFkdrkZ us uke
lgkjk-------------------------------- ---------------------------------
---------------------------;kstuk vfxze cqfdax ,MokUl ds #i
esa fn;k Fkk okLro esa dgha [kks x;k gS vkSj gj
lEHko iz;kl ds ckotwn Hkh ugha fey ldkA
3- ;gfd cgyQ c;ku djrk@djrh gwW fd mDr ls
lEcfU/kr ,Q0vkbZ0vkj0 fnukad------------------------- dks
lEcfU/kr Fkkus esa ntZ djk fn;k x;k gSA
4- ;gfd mDr dwiu dk nqckjk cukuk vfr vko';d gS rkfd
Hkfo"; esa tc Hkh vko';drk iM+s 'kiFkdrkZ mldk
mi;ksx dj ldsA bl lEcU/k esa eSa iw.kZ#i ls mRrjnk;h
gwWxk@gwWxhA
5- ;gfd cgyQ c;ku djrk@djrh gwW fd 'kiFk i= dk iSjk 1
ls 4 esjh tkudkjh esa lgh o lp gSA blesa tkucw>dj
dksbZ Hkh ckr fNikbZ ;k c<+kbZ ugha x;h gSA bZ'oj
esjh enn djsaA

fnukad-----------------------------------------
'kiFkdrkZ
uke----------------------------
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 Annexure BG-2
COUNTER GUARANTEE

Place:
Date:
The Branch Manager,
State Bank of India
....................................
....................................

In consideration of your having at our request a

Letter of Guarantee (as per copy annexed hereto) for
Rs................................
(Rupees..............................................Only) in favour of
the ......................................................................................
(hereinafter referred to as the beneficiary) we hereby
agree and declare that:

a) We will hold harmless and indemnify the Bank

against and will pay to the Bank on demand at State
Bank of India, ...................................Branch, the amount
of costs, claims demands, damages, losses, expenses
which may be made against or sustained by the Bank
having given and signed the said guarntee or otherwise
in connection therewith AND we also agree to pay to
the Bank at its..................................branch forthwith on
under the said guarantee (and whether the Bank shall
have paid any such amount or not ) plus all costs and
charges which may be incurred by the Bank or become
payable in connection with fulfillment of the terms of the
said guarantee AND any payment made by the Bank on
demand from the beneficiary shall be deemed to be an
amount which the Bank has been called upon to pay
under the said guarantee.
b) The Bank shall be at liberty to debit the
Current/Cash Credit maintained by us at the
Bank's ..........................................branch with any
amount paid or payable by the Bank pursuant to clause
(s) of this counter-guarantee.
c) We further agree that this counter-guarantee will
remain in force until the Bank is finally discharged of
the liability under the said guarntee and has obtained
confirmation in writing there of from the beneficiary and
received therefore the said guarantee duly redeemed.
(2)

d) Any notice by way of demand or the otherwise

hereunder may be given by the Bank to the company
by sending the same by post addressed to us at our
registered office and the notice shall be deemed to
have been given at the time when it would be
delivered in the ordinary course of post and it will be
sufficient in order to prove service of any such notice to
prove that the envelope containing the of the Bank's
....................................branch that the envelope was
posted shall constitute such proof.
e) If for any, reason or any action initiated by us, the
Bank is prevented from making payment to the
beneficiary of the guaranteed amount, we will be liable
to pay the Bank guarantee commission for the period
for which such action (i.e. the payment or discharge of
the guarantee) is delayed, apart from being liable for
other amounts payable to the Bank.

(Signature of the
applicant of the BG)
 3
(ii) If the miller delivers rice which is above the
rejection limit mentioned in prescribed specifications,
(Food Deptt Officers/FCI Officers) shall reject such rice
and the quantity so rejected shall be made good by
the miller within 7 days of rejection and such supply
shall be of the same varity as the miller would have
delivered had there been no rejection.
(iii) If the miller supplies rice less in quantitty than
the recovery percentage mentioned in sub-clause
(d), the miller shall compensate the PCF for the
quantities of rice in short supplies at the rate of one
and half times the prevailing market price of the
concerned variety of rice . The decision of the District
 Manager PCF regarding variety, specifications and
prevailing market price under sub-clause (d) & (e)
shall be final and binding on the miller.
(iv) The millar shall return all the gunny bags
supplied by the District Manager to the District
Manager, at the time of delivery of rice.
3.(i) The miller shall furnish to the PCF Bank
Guarantee according to the capacity of the miller's
rice mill as per table given below within a wek from the
date of this agreement :-
Bank
Guarantee
1. Rice mill of 1/2 ton capcity Rs.
1,50,000
2. Rice mill of more than 1/2 ton Rs.
2,25,000
but upto i ton capacity
3. Rice mill of more than i ton Rs.
3,00,000
but up to 2 ton capacity.
4. Rice mill of more than 2 ton capacity
Rs. 3,75,000
(ii) The bank guarantee shall be valid for a period of
nine months from the date on which this agreement
comes into force and should provide for its extention
from time to time till completion of the contract if
so request by the District Manager PCF.
(iii) If the miller duly performs and completes this
contract in all respects and returns in good condition
all property of the PCF remaining with him and presents
a 'No Demand Certificate' from the District Manager
PCF , The shall adjust any amounts recoverable from
the miller out of the Bank Guarantee.
4.(i) The miller shall ensure at his cost for the value of
the Paddy/Rice lying in his Factory premises
against all risk to safeguard the interest of the PCF
provided that if any existing insurance covers the
Paddy/ Rice for its full value and period under this
agreement against all risks no fresh insurance will be
required.

4
(ii) Withot prejudice to the requirement under sub
clause (i) above and the liability of the miller under
clause 2(c) the miller shall at the own expenses take all
such precaution as may be required by the District
Manager PCF to save Paddy and Rice from pest
infestation, loss destruction and deterioration, whether
prior to or in the course of or after the milling and shall
render account to the District Manager PCF of the same
from time to time as may be required by the District
manager PCF and shall also maintain a suitable fine
service in accordance with the Factories Act.
5. If the miller fails or noglects to observe or perform
any of his obligations under the contract, the PCF may
get the work executed at any other rice mill and
recover any extra expenditure incurred or damage
suffered by the PCF as a consequence of it from the
miller.
6. The issues and lifting of Paddy and delivery of rice
by the miller will be regulated as under:-
(i) The miller shall paintain close liaison with the
District Manager PCF in order to receive supply of
paddy.
(ii) When When the rice is ready for delivery the miller
shall send written intimation to the District Manager
PCF requesting him to arrange for delivery & there shall
be entered in such intianation the time and date on
which delivery of rice should be arranged. The miller
shall be responsible for transportation and delivery of
rice at the storage depot.
(iii) The Paddy supplied to the miller shall be weighed
on weigh bridge if such weigh bridge is ot available a
random sample of 10% bages shall be weighed.
(iv) The miller may get 100% weightment done but
complaints if any in respect of weight shall not be
entertained after delivery.
(v) The miller will have to return rice within 20
(Twenty) days of delivery of Paddy stocks . The miller
shall deliver the manufactured rice filled in bages
supplied by the District Manager PCF along with paddy
or otherwise at his premises. The rice bags will be
properly stiched with machine or with 16 strong
stitches and stencilled and the entire expenditure on
this account including the cost of 'SUTLI' & colour for
stencilling will be borne by the miller. If the miller fails
to deliver rice to the state pool or central pool as per
direction of District Manager PCF within the stipulated
period of 20 (twenty) days of delivery of paddy stock,
he shall be liable to pay by way of damages, holding
charges to District Manager PCF for such delay @50
(fifty) paise per quintal per day. Provided that if the
delay in supply of rice is for reasons beyond the Control
of the miller the Regional Manager PCF may for
sufficient resion duly recorded waive or reduce the
 5
holding charges. The decision of the Regional Manager
PCF in this regard shall be final and binding on the
miller. But in any case Regional Manager PCF/District
Manager PCF shall ensure the recovery of total due
C.M.R. from the rice mill at the most with in a month
after the end of paddey procurement scheme.
(vi) Any due for which miller is liable to PCF
procurement agency shall be recovered from the
guarntee of the miller in accordance with the provision
of agreement If any loss caused by the miller to the
PCF/ procurement agency by non delivery of C.M.R. or
by the delivery of revenue . Such a mill shall be
debared for a minimum period 5 years from C.M.R. and
levy work.
(vii) The delivery of rice shall be deemed to have been
completed after the stocks are weighed, inspected and
approved as of the required variety and of the
prescribed specifications and after being loaded into
trucks and deliver at the storage depot by the miller as
per directions of the District Manager PCF.
(viii)All expenditures including labour transportation
and any other incidental expenditure incurred in
connection with the unloading of paddy from trucks
and weighment and handling at the time of inspection
and loading of rice at the time of delivery shall be
borne by the miller and the same shall be deemed to
have been included in the milling charges as given in
slause 2(b) above.
(ix) Rice shall be packed in gunny bags supplied by the
District Manager PCF with paddy. The Miller shall return
the gunny bags to the District Manager P.C.F., originally
supplied with paddy duly bundled in lost of 50 in
countable position at the time of delivery of rice. He
shall given proper account of all gunny bags supplied
to him by the District Manager PCF. The rice shall be
packed in standradised weight in accordance with the
accordance with the instructions of the District
Manager PCF. The bages shall be stencilled indicating
the name of mill, the milling centre, the variety of rice
the net weight and any other particulars that may be
required to be stencilled as per instructions of the
District Manager PCF.
(x) If the miller dose not return all the gunnies
recoveries shall be made from the miller at the rate as
fixed by District Manager PCF in respect of gunny bags
delivered short.
7- Period of Contract :-
(i) The contract shall be valid for a period of nine
months from the date of this agreement or such
extended period as may be decided by the District
Manager PCF.
(ii) The District Manager PCF reserves the rights.

6
(a) to terminate this agreement at any time during its
validity without assigning any reason.
In such case the miller shall render to the District
Manager PCF complete account of paddy, rice and
gunny bags of the PCF in miller's custody and also
arrange to return the stocks as per directions of the
district Manager PCF in accordance with the terms of
the agreement.
(b) to withdraw fom the contract at any time any
miller work in whole or part of the stocks covered by
the contract but not yet delivered to him by the miller.
The decision of the District Manager PCF in this regard
suffered or alleged to have been suffered by the miller
on account of such withdrawl of the work.
8- Miller to carry out Instruction :-
The miller binds himself to carry out all such
instructions as are incidental to this agreement and
are issued by the PCF or its officers from time to time.
9- (a) The PCF does not guarantee any definite value
of work relating to milling of paddy at any time
throughout the period of contract.
(b) The mere mention of any item of work in this
contract does not by itself confer a right on the miller
to demand that the work relating to shelling of paddy
at a particular center/mandi should necessarly and
exclusively be entrusted to him. The District Manager
PCF will also have the exclusive right to appoint one or
more millers for any particular center/mandi and to
decide the work between such millers in any manner
that the District Manager PCF may decide and no claim
shall lie againts the PCF of District Manager PCF for
such withdrawal/distribution of work.
10- The PCF may recover any amount due from the
bank gurantee given by the miller.
11- Any loss incurred to PCF due to non delivery of
custom milled rice by the miller or due production of
suchrice which is not as specifications, will be
recovered as arrears of land revenue from the miller.
12- If any dispute relation to the matterof his
agreement arises between he PCF and the member
(miller) such dispute shall be referred to the Regirar
Cooperative Societies, U.P. for Arbitration in accordance
with the provision the U.P. Co-operative Societies Act
1965 (under section70). The arbitrator shall geven
award which shall be final and binding on both the
parties.
13- The expression district Manager PCF herein used ,
includes his offers and subordinates too entrusted with
any work relating to the this agreement.
14- The stamp duty on this agreement shall born by the
miller.

7
15- IN WITNESS WHEREOF the parties hereto have
signed there presents on the day and years first above
written.

FOR AND ON BEHALF OF FOR AND ON

BEHALF OF
THE U.P. COOPERATIVE FED. Ltd. OF THE
MILLER.
(PCF)
WITNESS:
1....................................................... ..................
............................
......................................................... ..................
.............................
(Name and Address) (Name and
Address)
1....................................................... ..................
............................
......................................................... ..................
............................
(Name and Address) (Name and
Address)
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eukscy c<+kukA
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;kstuk;sa pykukA
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djukA
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¼22½ tuleqnk; esa jk"Vªizse dh Hkkouk fodflr djus
gsrq Hkkjrh; egkiq:"kksa jk"VªHkDrkas rFkk LorU=rk
lsukuhvkas ls lEcfU/kr xksf"B;ksa] lsfeukj ,oa lkaLd`frd
dk;ZØeksa dk vk;kstu djuk o djkukA
¼23½ ckyd@ckfydkvkas esa vuq'kklu] jk"Vª HkfDr
,oa usr`Ro dh Hkkouk fodflr djus ds fy, mn~ns'; ls
lSfud izf'k{k.k] lkgfld vfHk;ku ,oa tutkxj.k gsrq ns'k
Hkze.k ds dk;ZØeksa dk vk;kstu djukA
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muds vf/kdkjksa] dRrZO;ksa vkSj nkf;Roksa ds izfr
tkx:d djus ds fy, le;&le; ij dkuwuh izf'k{k.k f'kfoj
yxkuk ,oa t:jreanksa dks fof/kd lgk;rk ,oa fof/kd
ijke'kZ miyC/k djkuk] vko';drkuqlkj ewyHkwr ukxfjd
lqfo/kkvkas o vf/kdkjksa gsrq dkuwuh igy djrs gq;s
fjV ;kfpdk o eqdnesa esa iSjoh djukA

¼25½ {ks=okfl;ksa esa LokoyEcu vkRefuHkZjrk dh

Hkkouk dks mRiUu djrs gq;s [kknh xzkeks|ksx
vk;ksx@cksMZ dh uhfr;ksa ds vuq:i f'k{k.k&izf'k{k.k dh
O;oLFkk djrs gq;s izf'k{k.k o mRiknu dsUnz
[kksyukA
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laLFkkvksa] foHkkxk laxBuksa tSls fu;kZr fuxe] y?
kq&m|ksx funs'kky;] efgyk dY;k.k fuxe] fiNM+k dY;k.k
fuxe] vYila[;d dY;k.k fuxe rFkk vU; laLFkkvkas ls vU;
foRrh; lgk;rk] vuqnku] ijke'kZ vkfn ysdj lekt ds
fu/kZu vuq0 tkfr] vuq0tutkfr] vYila[;d oxZ ds
yksxksa dks izf'k{k.k djrs gq;s LokoyECkh cukukA
¼27½ jk"Vªh; Lekjd] izkphu] /kjksgjksa ,oa lkaLd`frd
izrhdksa ds laj{k.k gsrq tu lkekU; esa tkxj:drk iSnk
djuk ,oa iz'kklfud Lrj ij vkxkg djukA
¼28½ lekt esa ,slh laLFkkvkas dk fuekZ.k djkuk tgkW
ij vukFk cPps] fujkfJr efgykvksa o o;kso`) ukxfjd ,d
lfEefyr ifjokj ds :i esa jgasA
¼29½ lekt esa ,slh f'k{k.k laLFkkvksa dk fuekZ.k
djkuk tgkW ij vukFk cPps o fu/kZu ifjokj ds izfrHkkouk
cPps cksfMZx lqfo/kkvksa ds lkFk&lkFk f'k{k.k izf'k{k.k
dk dk;Z fu%'kqYd :i ls izkIr dj ldsaA
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vkRefuHkZj cukus ds mn~ns';ksa ls lgdkjh [ksrh
dks c<+kok nsukA bl mn~ns'; dh iwfrZ gsrq
d`f"k&oSKkfudksa ds ek/;e ls d`"kd&xks"Bh]
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d`f"k foKku dsUnzksa dh LFkkiuk djukA e`nk&laj{k.k o
i;kZoj.k gsrq tSfod&d`f"k dks c<+kok nsukA d`f"k mit
ds csgrj ewY; gsrq foi.ku dh O;oLFkk djkukA
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lkFk feydj muds dk;kZs eas lg;ksx nsuk o ekuork ds
lexz fodkl gsrq fey tqydj lkFkZd iz;kl djukA
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pu# ;kno mez 57 o"kZ fuoklh eqgYyk
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oa'kcgknqj ;kno mez 25 o"kZ irk mijksDrA
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vktex<+A
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o"kZ xzke o iksLV& usoknk vktex<+A
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lsukMhg iksLV& vfeyk ftyk& eÅA

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foosd ls #i;k ,d gtkj 1000@&U;kl QUM esa tek dj
U;kl dh LFkkiuk djrk gwW rFkk mijksDr fu;qDr
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mn~ns';ksa ds vuq#i dk;Z dj ldsA mijksDr 1000
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djus gsrq U;kl ds vykoka vU; fdlh O;fDr ;k U;klh dh
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izhfe;e lwpuk] fo|ekurk fgr ykHk] iw.kZnkok
fgrykHk] 'kqHkdkeuk lUns'k vkfn ds :i esa
lk/kkj.k Mkd lsok }kjk :0 5]500-00 ¼ikWap gtkj
ikWap lkS½ ek= dk O;; fd;k gwWa A
d`i;k mijksDr en esa O;; :0 5]500-00
dk izfriwfrZ djus dh d`ik djsa A vfr d`ik gksxh A
 Hkonh;]

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 AGREEMENT
(Principal to Agent Basis)
 This agreement is made
at____________on_____________day
of________between Bharat Sanchar Nigam
Limited (BSNL), a Company incorporated under
the Companies Act, 1956 having its Registered
Office & Corporate Office at Bharat Sanchar
Bhawan, Harish Chandra Mathur Lane, Janpath,
New Delhi- 110001 (hereinafter referred to as
"BSNL" which expression shall be deemed to
include its successors and assigns wherever the
context so admits or requires) through its duly
authorised representative
Mr.__________________________________AGM, Mktg.
BSNL, U.P. (E) Telecom Circle, Lucknow ON THE
ONE PART and M/s _________________ (hereinafter
referred to as the "Franchisee" which expression
shall include his servants, heirs, executors and
administrators wherever the context so admits or
requires) through its authorised representative
Mr. ___________________ ON THE OTHER PART. This
agreement is meant for the extension of the
period of existing Franchisee wef. 1st April, 2008
to 30th November, 2009 to do marketing and
distribution of BSNL telecom services under its
Brand name on Principal to Agent basis i.e.
commission basis (as per Annexure-B of
amended New Sales & Distribution policy' 2006).
(2)

WHEREAS:

(a) The BSNL is desirous of extending the period

of agreement of existing Franchisee with a
viewto do marketingand distribution of its BSNL
Telecom Service under its Brand names for
which the BSNL has been licensed to provide
BSNL service.

(b) The Franchisee has approached the BSNL for

authorizing it to act as such an authorisee
Franchisee for marketing and distribution of BSNL
services subject to the terms and conditions
hereinafter appearing.

(c) The Franchisee has given an unconditional

Bank Guarantee (as per Annexure-D) Rs.
3,00,000.00 or Rs. 5,00,000.00 (Rs. Three Lacs
or Rs. Five Lacs) which shall be refundable for
the due fulfillment of the said agreement.

(d) The Bank-Guarantee mentioned at clause @

above is already available with the Marketing of
U.P. (E) Telecom Circle against the franchisee
agreement signed earlier as per the details given
below:

Bank Guarantee No.

Name of the Bank:
Amount of Guarantee:
Date of Expiry:

Since the same franchisee is being

permitted to continue upto______________________
the said BG shall hold good and shall be renewed
at lest one month before the date of it expiry in
case the date of expiry date
before________________________________.

Now it is hereby agreed by and between the

parties hereto as follows:
(i) This agreement shall come inestieffect
from_________________and will remain valid
upto_______________________. The right to
teminate the agreement prior to
___________________or to extend it thereafter
reserved with BSNL.
(ii) The franchisee shall have no objection to re-
demareation of the territory under his control
within the currency of this agreement and shall
abide by the terms & conditions of the New Sales
and Distribution Policy, 2006 and shall also
abide by further instructions or amendments
to be issued by BSNL of UP (E) Telecom Circle in
this matter.

Signature of Franchisee
Siognature of AGM (Mktd.)
 AFFIDAVIT

I/We Smt. Maya Yadav W/O Late Shri

Ishdutt Yadav resident of Mohalla: Sidhari,

Distt. Azamgarh do hereby solemnly affirm and

declare as under:

1. That I/We are the owners of tank lorry No.

UP50C 0880 bearing engine No.

697D24GTQ134676 Chassis No.

360044GTQ010259 make and model 1996

2. That I/We have attached/shall keep attached

the above mentioned tank lorry with M/S

ASHOK TRANSPORT till the validity of POL

Road Transport Contract awarded by B.P.C.L.

Mugalsarai in favour of M/S ASHOK

TRANSPORT.

Countd...2

(2)

3. That during above period M/S ASHOK

TRANSPORT alone shall have all the rights of

operating the said tank lorry and receiving

consideration for such operation.

 DEPONE
NT
VERIFICATION

Verified that the contents of the above affidavit

are true and correct to the best of my knowledge
and belief. No part of it is false and nothing has
been concealed therein.

DEPONE
NT

Verified at Collectorate Court, Azamgarh on

Dated: 21.12.2009

NOTARY
PUBLIC

UNDERTAKING
We declare as under:

1. That the tank-lorries offered under contract

to BPCL Mugalsarai Location has not been
withdrawan from any other contract with any
 other Oil Company or any other Location of
the BPCL.

2. That the tank-lorries under reference are not

attached with any other
Party/Contractor/Distributor and have not
been withdrawn without their prior consent.

3. That the subject tank-lorries are not involved

in any litigation other than routine cases of
road accident or any violation of Motor Vehicles
Act.

4. That we have not been blacklisted so far by

IOC/BPC/HPC.

5. We further confirm that the details as

furnished by us have been verified and found
correct. We undertake to place the tank-lorries at
the disposal of BPCL in case the contract is
awarded in our favour. If any information is
found to be incorrect, the contract if awarded to
us shall be liable to be cancelled and we shall be
liable topay to BPCL such
damages/losses/claims as BPCL may put to
due to termination of the contract. We also
undertake that, should there be any action
against BPCL resulting in damages of
whatsoever nature to BPCL on account of award
of contract inour favour on he basis of the
misrepresentations, we shall keep BPCL
completely indemnified against all the claims/
losses/ damages/ litigations/court action
etc.

Date: Signature
Name of Person
signing

Tender's Name and

address with seal
 GENERAL IRREVOCABLE POWER OF
ATTORNEY

We, the undersigned (1) Shri mOHD. nIZAM (2)

Shri_______ Brighunath Yadav (3) Shri Ashok
Kumar all residing at ____ the Partners/Directors
of M/S Ashok Filling Station having its
registered office at do hereby nominate,
authorize and appoint Shri_________ &__________
who are our Partners/Directors in the firm to act
as attorneys of our firm M/S Ashok Filling
Station with full power and authority to exercise
the following powers or any of them on our
behalf and on behalf of our firm.

i) To sign, seal, execute, perfect and/or

complete the tender document of
transportation of petroleum products and also
other relevant documents required by M/S
Ashok Filling Station Corporation Ltd.
(herebyafter called The Company) in respect
thereof.

ii) To negotiate, enter into correspondence with

the Company and do all and everything
necessary suitable or proper with regard to the
said tender for transportation of petroleum
products.

iii) To sign, seal, execute, perfect and/or

complete the Agreement for Hiring of Tank
Lorries and all and/or any other document,
Indemnity Bond etc.

iv) To do all acts, deeds, as may be necessary

for and incidental to the execution of proper
performance of the said agreement for Hiring of
Tank Lorries with BPCL.

We the said partner(s) do hereby agree to

allow verify and confirm all and whatsoever the
said Shri___________________and Shri___________
shall or may do or cause to be done in or about
the said tender and the Agreement for Hiring of
Tank Lorries, the execution and proper
performance thereof by virtue of these presents.
This Power of Attorney shall remain
irrevocable till the validity period of our
quotation/Agreement for Hiring of Tank Lorries/or
refund of our Security Deposit whichever is later.
In witness whereof, we have hereunto set
and subscribed our hands
at____________this__________day of__________Two
thousand Seven.

Signatures:

Signed, Sealed and delivered by 1)

Shri_________________
the within named partners 2)
Shri_________________

Directors of M/S_______________ 3)
Shri_________________

Before me,
Notary pubolic
(Notary's Stamp)
 AFFIDAVIT

I/We Smt. Maya Yadav M/S Ashok

Filling Station W/O Late Shri Ishdutt Yadav

resident of Mohalla: Sidhari, Distt. Azamgarh do

hereby solemnly affirm and declare as under:

1. That I/We are the owners of tank lorry No.

UP50B 6755 bearing engine No.

697D23KVQ143299 Chassis No. 360324MVQ

011392 make and model 1996

2. That I/We have attached/shall keep attached

the above mentioned tank lorry with M/S

ASHOK TRANSPORT till the validity of POL

Road Transport Contract awarded by B.P.C.L.

Mugalsarai in favour of M/S ASHOK

TRANSPORT

Countd.....2
 (2)

3. That during above period M/S ASHOK

TRANSPORT alone shall have all the rights of

operating the said tank lorry and receiving

consideration for such operation.

DEPONENT

DERIFICATION

Verified that the contents of the above

affidavit are true and correct to the best of my

knowledge and belief. No part of it is false and

nothing has been concealed therein.

DEPONE

NT

Verified at Collectorate Court, Azamgarh on

Dated: 21.12.2009

NOTARY

PUBLIC
 AFFIDAVIT

I/We Brighunath Yadav M/S

Brogjimath Filling Station S/O Sri Late Raghunath

Yadav Village: Doriya, Post; Dora (Sadat)

Ghazipur do hereby solemnly affirm and declare

as under:

1. That I/We are the owners of tank lorry No.

UP61C 5779 bearing engine No.

697TC45GXZ 108218 Chassis No. 373341HXZ

003344 make and model 2002

2. That I/We have attached/shall keep attached

the above mentioned tank lorry with M/S

ASHOK TRANSPORT till the validity of POL

Road Transport Contract awarded by B.P.C.L.

Mugalsarai in favour of M/S ASHOK

TRANSPORT
 (2)

3. That during above period M/S ASHOK

TRANSPORT alone shall have all the rights of

operating the said tank lorry and receiving

consideration for such operation.

DEPONE

NT

VERIFICATION

Verified that the contents of the above

affidavit are true and correct to the best of my

knowledge and belief. No part of it is false and

nothing has been concealed therein.

DEPONE

NT

Verified at Collectorate Court, Azamgarh on

Dated: 21.12.2009

NOTARY

PUBLIC
 AFFIDAVIT

I/We Mohammad Nizam S/O Sri

Maqsood R/O Nai Bazar, Bhadohi, S.R.N.

Bhadohi do hereby solemnly affirm and declare

as under:

1. That I/We are the owners of tank lorry No.

UP66D9912 bearing engine No. 697DZIBZZ

270537 Chassis No. 373094BZZ170925 make

and model 2000

2. That I/We have attached/shall keep attached

the above mentioned tank lorry with M/S

ASHOK TRANSPORT till the validity of POL

Road Transport Contract awarded by B.P.C.L.

Mugalsarai in favour of M/S ASHOK

TRANSPORT

3. That during above period M/S ASHOK

TRANSPORT alone shall have all the rights of

operating the said tank lorry and receiving

consideration for such operation.

DEPONE

NT

VERIFICATION

Verified that the contents of the above affidavit

are true and correct to the best of my knowledge

and belief. No part of it is false and nothing has

been concealed therein.

 DEPONE

NT

Verified at Collectorate Court, Azamgarh on

Dated: 17.12.2009

NOTARY

PUBLIC
 AFFIDAVIT

I/We Ashok Kumar S/O Sri Satai

Ram, R/O Vill. Katai Pawanikalan, Azamgarh

do hereby solemnly affirm and declare as under:

1. That I/We are the owners of tank lorry No.

UP50F 1770 bearing engine No.

697TC45BWZ104959 Chassis No.

373341WZ001931 make and model 2003

2. That I/We have attached/shall keep attached

the above mentioned tank lorry with M/S

ASHOK TRANSPORT till the validity of POL

Road Transport Contract awarded by B.P.C.L.

Mugalsarai in favour of M/S ASHOK

TRANSPORT

3. That during above period M/S ASHOK

TRANSPORT alone shall have all the rights of

operating the said tank lorry and receiving

consideration for such operation.

DEPONE

NT

VERIFICATION

Verified that the contents of the above affidavit

are true and correct to the best of my knowledge

and belief. No part of it is false and nothing has

been concealed therein.

DEPONE

NT

Verified at Collectorate Court, Azamgarh on

Dated: 17.12.2009

NOTARY

PUBLIC
 UNDERTAKING

We declare as under:

1. That the tank-lorries offered under contract

to BPCL Mugalsarai

Location has not been withdrawan from any

other contract with any other Oil Company or

any other Location of the BPCL.

2. That the tank-lorries under reference are not

attached with any other

Party/Contractor/Distributor and have not

been withdrawn without their prior consent.

3. That the subject tank-lorries are not involved

in any litigation other than routine cases of

road accident or any violation of Motor Vehicles

Act.

4. That we have not been blacklisted so far by

IOC/BPC/HPC.

5. We further confirm that the details as

furnished by us have been verified and found

correct. We undertake to place the tank-lorries at

the disposal of BPCL in case the contract is

awarded in our favour. If any information is

found to be incorrect, the contract if awarded to

us shall be liable to be cancelled and we shall be

liable topay to BPCL such

damages/losses/claims as BPCL may put to

due to termination of the contract. We also

undertake that, should there be any action

against BPCL resulting in damages of

whatsoever nature to BPCL on account of award

of contract inour favour on he basis of the

misrepresentations, we shall keep BPCL

completely indemnified against all the claims/

losses/ damages/ litigations/court action

etc.

Date: Signature

Name of Person

signing

Tender's Name and

address with seal

 I/We Smt. Maya Yadav W/O Late Sri

Ishdutt Yadav resident of Mohalla: Sidhari,

Distt.Azamgarh. do hereby solemnly affirm

and declare as under:

1. That I/We are the owners of tanklorry No.

UP50F 4137 Bearing engine No.

697TCS7ERZ127109 Chasis No. 373145

ERZ120290 Make and model 2008.

2. That I/We have attached/shall keep attached

the above mentioned tanklorry with M/S ASHOK

TRANSPORT till the validity of POL Road

Transport Contract awarded by B.P.C.L. in

favour of M/S Ashok Transport.

3. That during the above period M/S Ashok

Transport alone shall have the rights of

operating the said tanklorry and receiving

consideration for such operation.

DEPONENT

VERIFICATION

Verified that the contents of the above

affidavit are true and correct to the best of my

knowledge and belif. No part of its is false and

nothing has been concealed therein.

DEPONENT
 AGREEMENT FOR HIRING OF

GENERATORS

Shri Radhey Shyam S/O Shri Sati Ram

Yadav of resident of Mohalla: Baz Bahadur Kote,

Sadar, Azamgarh (hereinafter referred to as 'the

lessor(s)' which expression shall where the

context so admits includes him/her/them and

his/her/their heirs executors, administrators,

representatives, successors and assigns) of the

one part and THE STATE BANK OF INDIA,

constituted under the State Bank of India Act,

1955 and having one of the local Head Office at

Moti Mahal Marg, Hazratganj, Lucknow and one

of its Branch Office at MEHNAJPUR Distt.

Azamgarh (hereinafter referred to as 'The Bank'

which
 (2)

exprewssin where the context so admits shall

include its successors and assigns) ot the other
part WITNESSETHthat in consideration of the rent
of the generator to be installed by the lessor(s)
hereinafter reserved and the covenants and
agreements hereinafter contained and on the
part of the Bank to be observed and performed,
the lessor(s) hereby demises/demise and lease
unto the Bank the Generator belonging to the
lessor(s) to HAVE AND TO HOLD the demised
generator unto the bank for a term of (three)
years to be computed from the 1st day of
November Two Thousand Nine . The monthly rent
of the generator has been fixed at Rs. 4,900/-
(Rupees Four Thousand Nine Hundred) only
(including of all taxes, operating, lubricant and
maintenance

(3)

charges etc.) for the period 01.11.2009 to

31.10.2012 which would be payable before
the tenth day of every month from the
preceeding month.
The Bank hereby covenants with the
lessor(s) in manner following that is to say:-
(a) That the lesser(s) has/have good right, title
and power to grant this lease of the demised
generator to the Bank.
(b) That the lesser(s) will comply with at
his/their own cost all requirement and
regulations of the Municipality, Electricity
Board, pollution control Board and/or other
appropriate authority concerning the demised
generator and will keep the Bank indemnified
against any breach or consequences thereof
and in consequences there of if the bank suffers
any loss or damage, the bank shall have right to
deduct such loss or damages from the rent and,
if the rent is sufficient to recover the balance
from the lesser(s).
(c) That in case, due to fault in the power supply
from the generator the branch computer
systems, electrical wiring, electric gadgets,
automatic. Teller Machine etc. are damaged
the lesser(s) shall be responsible for the
damages
and cost of repair in g/replacement of any of
the part or whole of the equipment shaqll be
payable by the lesser(s) to the bank. If the
lesser(s), fail to do so, the entire cost as stated
above shall be recovered from the generator
rent.
(d) That the bank will pay or cause to be paid to
the lesser(s) the monthly rent hereby reserved
at the times herein before appointed for
payment thereof.

(4)

(e) That the bank shall pay monthly rent of the

generator @Rs. 4,900/- (inclusive of all taxes,
operating, luricant and maintenance
charges etc.) expenses of diesel will be born by
the bank.
(f) That the generator shall be installed by the
lesser(s) as per the instructions and suitability
of the bank.
(g) That the bank shall be free to use the
generator for the branch computer system,s
ATMs in the manner as deemed fit.
(h) That the rent shall not be increased before
the expiry of the terms of 3 years i.e. upto
31.10.2012.
(i) That the lesser(s) shall maintain the
genrator in good condition and shall provide the
full load.
(j) That the bank shall be free to check the
electricity load supplied by the generator to be
branch and in case any defic'ency is found,
the lesser(s) shall get it rectified
immediately in case, the load as agreed
upon between the bank and the lesser(s) is
less than the load agreed upon, the bank
shall be free to pay the rent depending upon the
actual load.
(k) That in case the generator goes out of order
the lesser(s) shall provide stand by generator of
the similar capacity with in two hours of the
break down otherwise lesser(s) shall be
liable to pay penalty at the rate of Rs. 500/-
per hour.
(l) That in case of breakdown if the lesser(s)
does not get the generator repaired within two
hours the bank may get it repaired through a
third party and the entire cost of repairs
alongwith the penalty of Rs. 500/- per hour
shall be

(5)
recovered from the lesser(s).
(m) That the bank shall be free to desire the
generator after giving notice of one month.
(n) That the lesser(s) shall have the option to
opt put of the agreement after giving notice
of three months to the bank.
(o) That the service tax and income tax shall be
deducted at the time of payment of monthly
rent, if applicable.
(p) That the lesser(s) shall provide the generator
service to the branch for 24 hours, a day
seven days a week including sunday/Holidays.

Bane(s) of Lessor(s): RADHEY SHAYM

Signature of Lessor(s) : ___________________
Date:

For and in behalf of State Bank of India

(Branch Manager)
State Bank of India
Thekma Branch
Date:
Witnesses:
Name Address
Signature
Civil Court, Azamgarh
(D.K. Pathak)
Advocate
Legal adviser to the Bank

Date:
 (Annexure-"A"
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THE YOUGH COORDINATOR NEHRU YUYA
KENDRA, AZAMGARH (U.P.)

AFFIDAVIT/UNDERTAKING DECLARATION

Name- Rinkoo W/O Sri Rajesh Kumar R/O Vill.

Baniyapar, Post- Bardeeha, Block: Harriya, The.
Sagari, Distt. Azamgarh (U.P.)
1. That I hereby certify that i have read the
brought of N.Y.S. Scheme and under stands
implications.

2. That I have understand that after completion

of work in N.T.S. Scheme will not be claim was
right to employ mention in the Department there
I am agreed.
3. That I undertake to abide by the terms and
conditions of the scheme I will service the entire
period of the year from date of training on
16.07.2009 in the protecting, I will not leave
this work, before the completion of this period
as desired by office concern.

4. That I undertake to abide by the discipline

and the rules Department during the Tenure of
my engagement as a valiation with that Agency
inheretent.

5. That I verify that I have neither registered

my self nor have I applied for Registration for
enrolment under N.Y.S. scheme at any other
Nehru Yuva Kendra Volunteer Agency.

6. That I verify that I have neither Registered

my self not have I applied for Registration for
enrolment under N.Y.S. Scheme at any other
Nehru Yuva Kendra/Volunteer Agency.
(2)

7. That I undertake and declare that if my sent

for i.e. Yough Coordinator is not satisfied with
my work of my service may at any time be
terminated without any notice.

8. That I will never claim employment nor

service in liue of the Department.

9. That I also undertake not to participate in

any Union or Association working against the
above department rules.

10. That if I leave my department during my

posting I undertake to report all stipend and
T.A. paid to till the date.
 At Azamgarh Dated: 28.01.2010

Witnesses:
Signatur
e of
1. Signature
Deponent
Address:

Witnesses:

2. Signature
Address:
 OTHER RELEVANT STATUES, RULER & FORMS

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SECTION-XI
AGREEMENT (SAMPLE)
No.................................................................................
...Dated at Azamgarh the................................
.....................................................................................
............................................................

This agreement made on this.........................day

of..............20........between hereinafter called "The
Contractor" (Which expression shall unless executed
by of repugnant to the context includes its
successor, heir and includes, administrative
representatives and assignees) of the one part and
the GMTD, Aamgarh BSNL hereinafter refereed to as
the BSNL of other part.
Where as the contractor has offered to enter
into contract with the said BSNL for execution of
work of trenching and pipe line, Optical fiber cable
pulling, Of cable splicing and the termination
preparation of joints, chambers, fixing painting and
sing writing of route/joint indicator and either
associated work (Optical Fiber Cable Construction
work) in ____________________zone of Azamgarh SSA
on the terms and conditions hereing contained and
the rates approved by the BSNL have been duly
accepted and where as the necessary security
deposit has been furnished in accordance with the
provisions of the tender documents and where as no
interest will be claimed on the security deposits.
Now these presents witness and it is hereby
agreed and deposited by and between the parties to
these present as follows.
1. The Contractor shall, during the period of this
contract that is to say
from_______________to__________________ or
completion of the contract period for
Rs._____________(in
word)___________________________________
 which ever is earlier or until this contract shall
be determined by such notice as is hereinafter
mentioned safely carryout, by means of labour
employed at his own

BEFORE THE SENIOR CUSTOMER SERVICES

EXECUTIVE (BIRTHS AND DEATHS) CITIZEN
SERVICES CENTRE for COMMISSIONER,
IMMIGRATION & CHECK POINTS

AFFIDAVIT ON BEHALF OF SADA BRIKSH

PANDEY
S/O LATE KRISHNAN ALIAS KRISHNA NAND
PANDEY:

1. I Sada Briksh Pandey stated on oath my name is

Sada Briksh Pandey and my father's Name is Late
Krishnan alias Krishna Nand Pandey and my perment
address is Vill. Tekan Gara, P.O.Amuari
Narayanpur, P.S. Jeanpur and Distt. Azamgarh (U.P.)
India.

2. That I stated on oath that I am enclosing the

deceased valid original Singapore N.R.I.C.
No.S0595238G cor cancellation as desired by
you.

3. That I stated on oath that the deceased died in

Taken Gara, P.O. Amuari Narayanpur, Distt.
Azamgarh (U.P.) India on 16th June, 2008 and
was cremated as for the Hindu rites &
rituals.Therrefore, it is confirm that his body was
not dispatched to Singapore. This fact is further
notified by the death certificate.
4. That oather Sada Briksh Pandey is only one son
of the deceased.

5. That I declare that all the contents of this

affidavit are true in my personal knowledge and
belief. Verified at Civil Court, Azamgarh (U.P.)
India on 06th February, 2010.

DEPONENT

AFFIDAVIT
I,_______________________________Son/Daughter/Wife
of___________________________________
Resident
of______________________________________________________
______________________
Affirm as under:
1. That I am an Indian national.
2. That I am residing
at______________________________________________________
_______
& enclosing a copy of Ration Card/Electricity
Bill/Rent Receipt/L.I.C. Policy/Flat allotment
letter/House registration paper as a residence proof.
3 That I am also enclosing a copy of Pan Card/Driving
Licence/Passport/Voter ID/other photo identity issued by
State/Central Government as a proof of identity 7 date
of birth.
4. That whenever I change my residence from present
address to another., I will inform my Indance
distributor in writing for change of address in his
record.
5. That I confirm that I am not in possession of an LPG
connection from any Oil Company for my domestic use.
Neither in my name nor in name of any of my family
member who are residing with
me.
6. That I confirm that the LPG connection issued to me
will be used in my above mentioned address only.
7. That I shall not position any other LPG gas
installations in the same kitchen.
8. That which second cylinder is issued to me I will use
the same in the same kitchen on the original
installations only.
9. That if any information/declaration given by me in
this affidavit or any document submitted in support
of identity/date of birth/residence proof shall be found
untrue or incorrect or false . Indian Oil Corporation
would be within its rights to withdraw the supply of
Gas/Terminate/Scize the equipments & that I would
have no claim , whatsoever against the Indian Oil
Corporation for such withdrawal/ Termination/
Scizure.
I hereby verify and confirm that what has been stated
above is true to the best of my knowledge, correct and
nothing material has been concealed therefrom.
Solemnly affirmed and deciared before me
this_______________day of______________.

Signature & Seal of Signature of

person make
Notary Public Affidavit

ANNEXURE-VII
 AFFIDAVIT

I, Smt. Subhagi Ahirin, aged 72 years,

wife of Late Ramraj Ahir resident of Vill. Saidpur,
P.O. Arazi Amani, Tehsil-Sagri, Distt. Azamgarh
(U.P.) do hereby solemnly affirm and state as
under:

1. That my spouse Late Shri Ramraj Ahir

joined Burmah Shell Group of Companies on
19.10.1948 as Worker at Budge-Budge.

2. My above named spouse was a regular

employee of Burmah Shell Group of
Companies/Bharat Petroleum Corporation
Limited. He was not engaged on
Contractual/Daily Wages basis in Burmah Shell
 Group of Companies/Bharat Petroleum
Corporation Limited.

3. My above named spouse served Burmah

Shell Group of C ompanies/ Bharat Petroleum
Corporation Limited for 15 years contrinuously
(without break jointly/serverally) and
separated from the services of Bharat
Petroleum Corporation Limited on
31.12.1984 as General Worknan from
BPCL, Budge Budge.

(2)

4. My above named spouse was not

dismissed/removed/terminated or had not
resigned from/opted for VRS/early
retirement/abandoned the services of
Burmah Shell Group of Companies/Bharat
Petroleum Corporation Limited.
5. The Ex-Gratia payment being given to me is
not because of any right or entitlement, but
purely as an Ex-Gratia.
6. I further, confirm that I shall not enter into
any litigation singly/ collectively against
Bharat Petroleum Corporation Ltd. in regard to
any service related matter before any Court
of Law/Forum/Authority.

(DEPONENT)

VERIFICATION
 I, above named deponent hereby declare
and verify that the above mentioned facts from
para 1 to 6 above are true to the best of my
knowledge, belief and information.
Signed and verified this____________day
of___________2010.

(DEPONENT
)

IDENTIFIED BY:

NAME:
SIGNATURE

(To be attested by Notary)

Annexure-V
 UNDERTAKING

I, Smt. Subhagi Ahirin, spouse and legal heir of

Late Ramraj Ahir who expired on 24.08.2009 and
retired Bharat Petroleum Corporation Limited on
31.12.1984 as General Workman, PF No. CBL/3588,
Vill. Saidpur, P.O. Arazi Amani, Tehsil-Sagri, Distt.
Azamgarh (U.P.) .

1. That , I recognize and unconditionally admit and

accept that my request for grant of Ex-Gratia' is
not based on any right or entitlement whatsoever,
but entirely as an Ex-Gratia benefit.
2. That, I expressly understand and acknowledge
that the grant of such an Ex-Gratia benefit will not
create any right, privilege or claim whatsoever, to me
individually or collectively qua Burmah Shell Group
of Companies/Bharat Petroleum Corporation
Limited/Kochi Refineries Ltd. entitling for claiming any
cause before any Court of Law/Forum /Authority and
I further expressly waive any such right, privilege or
claim.
(2)

3. That I have not entered into any litigation either

singly or collectively against Burmah Sheel Group
of Companies/Bharat Petroleum Corporation
Limited/Kochi 6. That, I am executing this
undertaking on my free will.
Encl. As above
Refineries Ltd. relating to my service and/or service
conditions including Pension/Superannuation Scheme,
before any Court/Forum/ Authority.

4. That, I undertake to submit Life Certificate every

year to authority who disburses Ex-Gratia payment.

5. That, I undertake to refund the Ex-Gratia amount

received by me under the Monthly Ex-Gratia
Scheme along with 12% interest p.a. to the
Corporation, in case facts submitted by me are found
to be incorrect.

(Signature)
and
Name of the
Executant

Place:

Date

To be attested by Notary
To
The Executive Engineer,
Provincial Division,
P.W.D. Jaunpur.

Sub: Quotation for overhead structure and sign Board.

Respected Sir,

I am agree to supply and fixing of following material at

your site.

Sl. Particulars Qnty Rate Cost Rs.

No. .
1 Supply of overhead structure 1 No. Rs.
with two vertical post of 6m. 106000.00
height made upto 300mm.N.B.
Medium Class M.S. Pipe as
vertical welded with 100mm.
M.S. Plate as top and bottom
bearing and horizental frame
comprising of 32mm. N.B.
Medium class main pipe and
25mm. Class medium N.B. pipe
 bearing as per approved coats of
steel primer and two coats of
synthetic paint as per direction of
Engineer-in-Charge.

(a) 10mt. to 25Mt. span structure

.
2 Supply of retro reflective signage 54 14950.00/S
made of 2mm. thick aluminium Sqm. qm.
composite Pandel sehet face to
be fully covered with retro
reflactive sheeting of approved
as per M.O.R.T. & H.
specification having approved
massage fully processed by
Avery Dennision Company
(USA) or equivalent as per
specified by other brands. Back
of aluminium sheet will be
provided with frame 40x40mm
angle iron with proper clamping
arrangement to be fixed
overhead structure. The back of
aluminium sheet will be power
coated.

(a) High Intensity Grade

Sheeting (Series (T.5500) (2
Nos.x13.5mx2m)= 54m.
3 Fixing of welded built up 1 18000.00
overhead structure including Job
excavation of foundation
providing lean concrete 1:3;6,
with Cement coarse sand
approved 20mm. gauge grit &
R.C.C.1:2:6 Complete as per
approved drawing and design
including all charges and labour
charges for fixing of massage
boards in overhead structure as
per direction of Engineer-in-
 charge.

Total:

TERMS & CONDITIONS:

1. VAT @13.5% applicable shall be paid extra.

2. 10% Transportation & Installation Charge is extra.

With thanks
Yours faithfully,

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 AFFIDAVIT
Before Regional Manager, Tata Chemcials Limited

I, Surendra Nath Singh aged about 65 years S/o Shri. Late

Baldeo Singh R/o Paharpur, Post- Sadar, P.S.- Kotwali,
Distt- Azamgarh (U.P.) do hereby affirm and state on oath as
under-:

1- That the deponent is Proprietor of Firm M/s Rajpoot

Agencies
2- That the deponent is having properties in his own name
(As detailed below).
A- Properties
Name & Address of Property Present
Market
Value (Rs. Lacs)
1- Shop, Paharpur, Azamgarh 45.00
2- Godown, Paharpur, Azamgarh 25.00
3- Godown, Devkhari, Azamgarh 30.00
4- Agriculture land, Devkhari, Azamgarh
400.00
5- Agriculture land, Daraura, Azamgarh
100.00
3- That the deponent undertakes to infrom the company from
time to time about the changes (If any) made in above
properties by way of sale of existing properties and any addition
by way of purchase of other propertis.
Date:
Place:
DEPONENT
VERIFICATION
I, the above named deponent do hereby verify that the contents
of above Paras 1 to 3 are true and correct to the best of my
knowledge and belief.

Signed and verified this Day of at

Date:
Place:
DEPONENT