Qubyk Services Pvt. Ltd.
APPLICATION FORM FOR ENTREPRENURE
Qubyk Services Pvt Ltd
1.Location(Village/Town)Location____________________________Distric____________________________________________
State_________________________Pin____________________________________________
2.Name (IN BLOCK LETTERR)_______________________________________________________________________________
3.Father’s/Husband Name
______________________________________________________________________________
4. Date of Birth(Age)
______________________________________________________________________________
5. Gender (Please Tick) -
Male
___________ Female ___________________________________________________
6. Marital Status (Please Tick) - Married ____________________________Unmarried ___________________________________
7. Education (Please Tick) - Class X ______ Class XII ______ Graduate ____ Post Graduate and above
8. Permanent Address
Mohalla / Village______________________________________________________________
Post___________________________________Tehsil________________________________
Distric__________________________________State_________________________________
Pin Code_____________________________________________________________________
9.Communication Address
Mohalla / Village______________________________________________________________
Post___________________________________Tehsil________________________________
Distric__________________________________State_________________________________
Pin Code_____________________________________________________________________
10.Telephone(With STD Code)
Residence_________________________________Office_______________________________
Mobile Number_________________________________________________________________
11. Email ID(With any)
____________________________________________________________________________
12.Curently Bank (With Bank)
_____________________________________________________________________________
13. Bank Account Number(If any)
_____________________________________________________________________________
14. Cheque Facility (Please Tick)
_____________________________________________________________________________
Qubyk Services Pvt Ltd
15. Present Bussiness / Occuption, If any
_________________________________________________________________________________
16. Computer Literacy
_______________________________yes _______________________No______________________
17. If Yes Nature of Qualification
__________________________________________________________________________________
18. If You Already Own A Bussiness or Are Working Your Revenue / income Per Month Including Pension if Any is
less Than Rs.5000- Rs,1000
Rs.10000---------------Rs-20000
Rs----20000 ---Rs-30000 More Than Rs -30000
(Please Inclose Copy of I.T. Return / pensio Payment certificates)
Do You have Any experience in selling Financial products ? If yes , Give Details
19. Language known (say fluent / not so fluent)
Read
write
Speak
20. No. of years of stay in the town / village
In town
In Village
21. Do you have any police records? If yes, give details.
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
22. Name, address and occupation: ___________________________________________________________________________________________
Of two people to whom reference can be made________________________________________________________________________________
23. Political Affiliation, if any: - ________________________________________________________________________________________________
24. Default if any to Banks / Financial Institutions: - ________________________________________________________________________________
25. Infrastructure available: (Office, area, location, computer, Internet, Tel No, etc) :- _____________________________________________________
_____________________________________________________________________________________________________________________
26. Name of the office from which retired. :-______________________________________________________________________________________
27. Position at the time of retirement ___________________________________________________________________________________________
(Plz. give brief of various positions held and role)
Qubyk Services Pvt Ltd
28. Any disciplinary action taken against you while in service
(if Yes, please give details. Please enclose a certificate of Conduct from your last the employer)
29. Particulars of liabilities: -___________________________________________________________________________________________________________________
30. Particulars of movable property and Investment. :- ______________________________________________________________________________________________
32.
Particulars of Immovable property. :- Land___________________, Village ________________________
Survey/PattaNo. _________________, Area _________________
33.
Are you willing to invest in the POS/Kiosk machine and other equipment required for carrying out transactions as CSP / KO of Business Correspondents?
What is the cash balance you are ready to invest for making cash payments / receipt of deposits
as Business Correspondent?
;
Date :- ______________
Place :- ______________
Signature of the Applicant
Qubyk Services Pvt Ltd
SCORING SHEET FOR CUSTOMER SERVICES POINT / SUB-AGENTS/FRANCHISEE
Name of the Applicant: - _________________________________________________________________________________________________________________
Category of Applicant: - __________________________________________________________________________________________________________________
Part - A - Quantitative Assessment
SR No
Parameter
1
Office A
2
Employer’s **
certificate
submitted
(if employed in
Marks
Criteria
i) Non-residential
ii) Residental
iii) Located elsewhere at the centre
5
2
2
i) Satisfactory conduct certificate submitted
ii) ii) Not submitted
5
1
Max Marks
5
2
2
past)
3
Opinion Report of
Present Banker
bank
4
References of two
persons known to
i) Submitted / Acceptable
ii) Not submitted / Not-acceptable
i) Submitted / Acceptable
ii) Not submitted / Not-acceptable
1
0
1
0
1
1
bank
Distance-area of
5
operation
i) Distance between the place of business of VLE& link
branch in within 15 Kms.
ii) Beyond 15 Kms to 30 Kms
2
1
2
Marks scored