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    Sample Dsa Application Form

    Uploaded by

    ANUJ KUMAR
    This document is an application form for individuals or entities seeking empanelment as a Direct Selling Agent (DSA) to represent Central Bank of India. The form requests information such as the applicant's name, date of birth/incorporation, address, contact details, qualifications, existing banking relationships, assets and liabilities. It also asks for details on the applicant's office infrastructure and past work experience. By signing the form, the applicant agrees to various terms and conditions such as adhering to the bank's rules, updating their information and assisting with loan recovery. Required documents like identity, address and qualification proofs must be attached with the completed form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Sample Dsa Application Form

    Uploaded by

    ANUJ KUMAR
    1K views4 pages
    This document is an application form for individuals or entities seeking empanelment as a Direct Selling Agent (DSA) to represent Central Bank of India. The form requests information such as the applicant's name, date of birth/incorporation, address, contact details, qualifications, existing banking relationships, assets and liabilities. It also asks for details on the applicant's office infrastructure and past work experience. By signing the form, the applicant agrees to various terms and conditions such as adhering to the bank's rules, updating their information and assisting with loan recovery. Required documents like identity, address and qualification proofs must be attached with the completed form.

    Original Description:

    APPLICATION

    Original Title

    SAMPLE DSA APPLICATION FORM (1)

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    This document is an application form for individuals or entities seeking empanelment as a Direct Selling Agent (DSA) to represent Central Bank of India. The form requests information such as the applicant's name, date of birth/incorporation, address, contact details, qualifications, existing banking relationships, assets and liabilities. It also asks for details on the applicant's office infrastructure and past work experience. By signing the form, the applicant agrees to various terms and conditions such as adhering to the bank's rules, updating their information and assisting with loan recovery. Required documents like identity, address and qualification proofs must be attached with the completed form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    1K views4 pages

    Sample Dsa Application Form

    Uploaded by

    ANUJ KUMAR
    This document is an application form for individuals or entities seeking empanelment as a Direct Selling Agent (DSA) to represent Central Bank of India. The form requests information such as the applicant's name, date of birth/incorporation, address, contact details, qualifications, existing banking relationships, assets and liabilities. It also asks for details on the applicant's office infrastructure and past work experience. By signing the form, the applicant agrees to various terms and conditions such as adhering to the bank's rules, updating their information and assisting with loan recovery. Required documents like identity, address and qualification proofs must be attached with the completed form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    Application Form for Direct Selling Agent (DSA)

    The___________________,
    Central Bank of India, Photograph

    ______________________,

    SUB: Application for Empanelment as Direct Selling Agent (DSA) with Central Bank
    of India
    I/We submit herewith my/our application for the empanelment as Direct Selling Agent
    (DSA) for Central Bank of India at __________________ Branch / Office. I/We have read
    all the terms and conditions relating to the service and undertake that all the terms and
    conditions are acceptable to me/us.
    1. Full Name (in Block letters) (Name
    of the person/ Proprietor/ Firm/
    Company
    2. Father’s / Husband’s Name
    3. Constitution (Individual/
    Proprietorship/Partnership/
    Company)
    4. Date of Birth / Incorporation
    (dd/mm/yy)
    5. Age
    6. Address
    7. Mobile Number
    8. Alternate Contact Number
    9. PAN Number / TIN Number
    10. E Mail id
    11. Present Occupation
    12. Present Income Rs.
    13. No of years in current employment
    14. Qualification
    15. Languages Known
    16. Presently banking with Name of the
    Bank Branch Account Number
    17. Reference (Name and contact
    Number)
    18. Details of assets
    19. Details of liabilities
    20. Relative to existing staff (if Yes)
    Please furnish the full details of the
    staff member

    Signature of the applicant


    INFRASTRUCTURE AVAILABILITY
    No of Computer available

    Connectivity (e mail , internet etc)

    No of telephone lines available

    Office space ( in Sq ft)

    Owned or Rented

    Number of employees

    Fax available

    Past / Present Relationships

    Name of the Institution

    Nature of Work

    Period of association

    Volume of work

    Reasons for termination

    Any other information which the applicant wishes to bring to the knowledge of the
    Bank:
    I/We declare that the statement in this application and the documents submitted (as per
    list given below) are true, complete and correct to the best of my/our knowledge and
    belief. I/We further, declare that I/We am/are not related to any existing employees of
    Central Bank of India. I/We understand that in the event of any information/document
    being found untrue/incorrect at any stage my/our application is liable to be rejected and if
    already empanelled, the empanelment is liable to be terminated. I/We declare, that no
    criminal proceedings are pending against me/us.
    I/We hereby undertake that I/We have studied and understand the rules and regulations
    of Central Bank of India for my/our engagement as DSA. I/We also confirm that I/We are
    not working as DSA for any other HFC/ Bank, other than as disclosed in the Application
    Form. I/We further undertake as under:
    1. I/We declare that all the particulars and information given in this Application
    Form, including the details provided in, are true, correct, complete and up to
    date in all respects and I/We have not withheld any information. I/We confirm
    that I/We have had no insolvency proceedings initiated against me/us nor have
    I/We ever been adjudicated insolvent. I/We have read the Application Form and
    am/are aware of all the terms/conditions in this Application Form.
    2. I/We also authorize the Central of India to exchange, share part with all
    information relating to my/our details and history information to other
    Banks/Financial Institutions and Housing Finance Institutions.
    3. I/We undertake to inform the Central Bank of India regarding change in my/our
    employment address and to provide any further information that the Central
    Bank of India may require. I/We understand that the Central Bank of India has
    the right to reject my application without providing any reason.
    4. I/We will be responsible for canvassing the business and identification of the
    Borrower and the property being financed & to assist in recovery of dues in the
    event of any default of repayment of loan amount.
    5. Central Bank of India would not be bound to sanction cases brought by me/us
    and the final decision in this regard would rest with the Central Bank of India or
    any other person authorized by it.
    6. I/We am/are agreeable to execute at my cost an agreement with the Central
    Bank of India to work as DSA.
    7. I/We undertake to abide by all rules and regulation as prescribed by Central
    Bank of India to be a DSA.
    8. I/We hereby accord our consent that fee structure prescribed by Central Bank
    of India for canvassing the business is acceptable to me/us and the Bank will
    have right to change the fee structure
    9. I/We will keep bank updated as regards to any change in my personal profile,
    i.e., change in address, Mobile Number, Employer, New Agency etc.

    Signature & (Seal if applicable) of the Direct Selling Agent:


    Place:
    Date:
    Enclosures:
    • Self-attested copies of the following documents along with application form
    a. Copy of PAN card
    b. Copy of Voter Card / Aadhar card
    c. Bank statement for last six months
    d. Education qualification
    e. IT returns for the last three years (if applicable)
    f. Firm registration / incorporation / constitution letters
    g. Net worth details proofs
    Details required and list of documents to be attached along with application form
    Proprietorship firm:
    • Sole Proprietorship letter
    Partnership firm:
    • Partnership deed
    • Authority letter in favour of one of the partners of the firm by all other partners,
    authorizing him /her to act on behalf of all such partners
    Private Limited Company:
    • Memorandum of Association and Articles of Association
    • Certificate of Incorporation
    • Certificate of Commencement of Business
    • Relevant Board Resolutions

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