jsmfdc.ranchi@gmail.

com
Photo of Applicant

NAME/uke : MS. /MRS/dqekjh /Jherh :

W/O,/D/O:/ ifr / firk dk uke :

MOTHER'S MAIDEN NAME/ ekrk dk ek;ds dk uke :

ADDDRESS / irk %&

ADDDRESS / irk

VILLAGE / Cykd

DISTRICT / ftyk

STATE / jkT;

PINCODE / fiudksM

MOBILE NO / eksckbZy uacj

OTHERPHONE NO / vU; Qksu uacj

DATE OF BIRTH / tUe rkjh[k

Age / vk;q : _years/ o"kZ GENDER/ fyax : Female/efgyk Male/ iq:"k

KYC DOCUMENTS/ igpku nLrkost

PHOTO ID : ( ) PAN Card ( ) Driving Licence ( ) Adhaar ( ) Voters ID ( ) Others ( _)
QksVks igpku i= : ( ) isudkMZ ( ) Mªk;foax yk;lsal] ( ) vk/kkj ( ) ernkrk ifp;&i= ( ) vU; ( _)

ADDRESS : ( ) Electricity Bill ( ) Telephone Bill ( ) Ration Card ( ) Others ( _)

irk : ( ) fctyh dk fcy ( ) VsyhQksu fcy ( ) jk'ku dkMZ ( ) vU; ( _)

MARITAL STATUS ( ) Married ( ) Unmarried ( ) Widow ( ) Divorcee

oSokfgd fLFkfr % ( ) fookfgr ( ) vfookfgr ( ) fo/kok ( ) rykd'kqnk

Community ( ) Hindu ( ) Muslim ( ) Christian ( ) Other …………………. lEÁnk;@lekt

( ) fgUnw ( ) eqfLye ( ) fØf'p;u ( ) vU; ......................

CASTE ( ) General ( ) OBC ( ) SC ( ) ST ( ) Other……………………………

tkfr ( ) lkekU; ( ) vkschlh ( ) ,lh ( ) ,lVh ( ) vU; ……………………………..
 FAMILY MEMBER DETAILS/ ifjp; ds lnL;ksa dk fooj.k %&
Sl. Name/uke Reelationship/fj'rk Age (years) Working/Not Daily Annual
No./vuq- vk;q ¼o"kZ½ Working Income Income
dk;Zjr@vdk;Zjr nSfud vk; okf"kZd vk;

1
2
3
4
5
6
Total Annual Family Income/ dqy ikfjokfjd okf"kZd vk;

OTHER LOANS AVAILED & CREDIT HISTORY/ÁkIr fd, x, vk; _.k @lk[k lqfo/kvksa dk fooj.k %&
Organiation Name / Losn Amouny/ ÁkIr Monthly Outstanding / Remarks / fVIi.kh
laLFkk dk uke _.k jkf'k Installment/ekfld nS; cdk;k ns; jkf'k
jkf'k

LAND & OTHER ASSETS/Hkwfe rFkk vU; laifRr %&

Assets / laifRr Value / ewY;kadu

Total / dqy

Loan Amount requested /vkosfnr@ÁkfFkZr _.k jkf'k ¼:i;s½

Purpose of Loan/ _.k dk Á;kstu@mn~ns';
Experience in activity(years)/ xfrfof/k esa vuqHko ¼o"kZ½
Proposed loan tenure/ _.k dh ÁLrkfor vof/k
Repayment frequency/ vnk;xh dh vko`fr

EDUCATION QUALIFICATION :- ………………………………………………………………………………………………

'kS{kf.kd ;ksX;rk %&……………………………………………………………………………………………………………………….

I declare that the information and data furnished by us are true and correct to the best of my knowledge
and belief.
eSa ?kks"k.k djrk@djrh gwa fd] gekjs }kjk nh xbZ tkudkjh esjs Kku ,oa fo'okl ls lR; o lgh gSaA

Thumb Impression Signature of Applicant

fu'kkuh vaxqBk vkosnd ds gLrk{kj
Date fnukad %
 Photo of Applicant
jsmfdc.ranchi@gmail.com

ekg
A B

C D

E F

Z
1- Xkj.Vj dk uke %

2- LFkk;h irk %

3- dk;Zjr dk;kZy; dk iwjk irk %

4- inuke %

5- xkj.Vj ds lsok fuo`fr dh frfFk %

6- xkj.Vj ds py&vpy ¼foØ;’khy½ lEifŸk dk fooj.k %

7- py&vpy ¼foØ;’khy½ lEifŸk dk vuqekfur eqY; %

8- xkj.Vh ds :i esa j[ks x;s ewy vfHkys[k %

9- xkj.Vj ds cSad [kkrk dh fooj.kh %

i. cSad dk uke %
ii. [kkrk la[;k %
iii. vkbZ,Q,llh dksM %

eSa ,rn~ }kjk ?kks"k.kk djrk gw¡ fd vkosnd Jh@Jherh -----------------------------------------------------------------------------------

ds }kjk ---------------------------------------------------------------------------- ds ,ot esa fy, x;s _.k dh Hkqxrku dh eSa xkj.Vh ysrk
gw¡A vkosnd ds fMQkWYVj gksus dh fLFkfr esa esjs py&vpy ¼foØ;’khy½ lEifŸk ls lacaf/kr vfHkys[k tks
xkj.Vh ds :i esa j[kk tk jgk gSA olwyh ;ksX; jkf’k dk lek;kstu esjs }kjk dj fn;s tkus ds i’pkr~
py&vpy ¼foØ;’khy½ lEifŸk dks xkj.Vh ds :i esa j[ks x;s vfHkys[k ykSVkbZ tk ldrh gSA

xkj.Vj dk gLrk{kj