UNION HEALTH APPLICATION FORM

UNION HEALTH APPLICATION FORM
AFFIX RECENT
PHOTOGRAPH OF
APPLICANT
WITH
SIGNATURE
1. Please write or type in Block Letters.
2. Put a tick mark against appropriate item.
3. Ensure that all information is correctly filled in. If any detail is not applicable,
please write “N.A”.
4. Enclose all required supporting documents and project report.
Purpose of Loan:
Loan Amt.:
PERSONAL AND EMPLOYMENT DETAILS
Name
Surname
First Name
Middle Name
Current Residential
Address
Phone No.
E-mail (if any) Male
Date of Birth (ddmmyy)
____________
Marital Status
Single
Married
Children Others Resident
Non-Resident
MBBS / MD / Other (please specify)
Employed
Self-Employed
Number of dependants
Status
Qualification
Occupation
Age:
Yrs
Female
EMPLOYMENT RECORD – FOR SALARIED / SELF EMPLOYED
Name of the Employer
Company / Firm Address
(Please mention the
address of the office you
are based at)
Designation
No. of year in Current
Employment business
Office phone No.
Monthly Income
Other Income
No. of yrs in present occ.
Department / Section :
Years :
Employee No.
Income Tax Permanent a/c no.(PAN) :
Ext. (if any) :
Date of Salary Receipt:
Rs
Rs
Yrs
Fax:
Retirement Age:
Yrs
FINANCIAL INFORMATION
Savings, Investments Etc.
Particulars
Applicant
Co-applicant
(Rs)
(Rs)
Savings in Bank
__________ ____________
Immovable property
(specify) ___________________________________
__________________________________________
Current balance in
Provident Fund (your share)
_________________
Other Assets (specify)
1.
____________ ___________
2.
____________ ___________
LIC Policy(ies)
____________ ___________
Postal Life Insurance
Policy(ies) Amount ____________ ___________
Maturity Dates
____________ ___________
Loans Taken / Proposed
Please indicate below all loans taken / proposed from
employer, Provident Fund etc., and installment(s)
payable per month including interest against each loan.
Source
Of Loan
(Rs)
Outstanding
Amount
Applicant:
Employer
Provident Fund
Credit Society
Others (specify)
Co-applicant
Employer
Provident Fund
Credit Society
Others (specify)
_________
_________
_________
(Rs)
Monthly
Installment
Payable
(months)
Term
_________ __________
_________ __________
_________ __________
_________ _________ __________
_________ _________ __________
_________ _________ __________
BANK ACCOUNT DETAILS
Name of the Account Holder Name of the Bank & branch Year a/c opened
Account No.
GENERAL [APPLICABLE TO APPLICANT AND CO-APPLICANT (IF ANY)]
What other security will you be able to provide Are you a citizen(s) of
_____________________________________ India?
1. Have you or your spouse earlier
4. Please select the mode of repayment convenient Yes
No
applied to UBI for a loan ?
to you: Tick () against the appropriate box.
If yes a) Loan a/c no. _______
a) Deduction of monthly installment
Do you belong to
b) Other details ____________
By your employer
SC
ST
NA
b) Post dated cheques
2. Have you or your spouse given
Do you have any Credit
c) Standing instructions to bankers
Personal Guarantee(s) ?
Cards? Yes / No
d) Any other (please specify) ____________
If yes, a) On behalf of ___________________
If Yes, Card No.:
Not applicable for employed applicants, whose
b) Name of the organisation______________
employers have a deduction at source arrangement
c) Amount ______________
Issuers name:
with UBI?
Yes No
3.
REFERENCES (NAMES AND ADDRESSES OF TWO REFEREES WHO ARE NOT RELATED TO YOU)
UBI may make such
enquiries from the
referees if it deems
necessary.
Phone
1.
2.
Off:
Res:
Off:
Res:
DECLARATION
I / We declare that all the particulars and information given in the application form are true, correct and they shall
form the basis of any loan UBI may decide to grant me / us. I / We confirm that I / We have had no insolvency
proceedings against me / us nor have I / We ever been adjudicated insolvent and further confirm that I / We have
read the brochure and understood the contents. I / We am / are aware that the Equated Monthly Installment
comprising principal and interest is calculated on the basis of quarterly rests. I / We agree that UBI may take up
such references and make such enquiries in respect of this application, as it may deem necessary. I / We undertake
to inform UBI regarding any change in my / our occupation / employment and to provide any further information that
you may require. I / We also undertake to authorise my / our employer(s) to deduct Equated Monthly Installments
from my / our salary and remit the same to UBI directly every month. UBI may make available any information
contained in this form, other documents submitted to UBI and information pertaining to the loan to any institution or
body. UBI may seek / receive information from any source / person to consider this application. I / We further agree
that my / our loan shall be governed by rules of UBI which may be in force from time to time.
Applicant’s Signature
FOR OFFICE USE ONLY
All the documents obtained as per scheme, verified with original (wherever applicable) and found to be in order
(Signature & name of processing officer)
SANCTIONED / DECLINED
(Signature & name of sanctioning authority)