Version : 1.

3
fuca/ku la[;k
CM7RBSCC092021004001975

BIHAR STATE EDUCATION FINANCE CORPORATION LTD.

BIHAR STUDENT CREDIT CARD SCHEME

fcgkj LVwMsUV ØsfMV dkMZ ;kstuk
APPLICATION CUM APPRAISAL FORM FOR EDUCATION LOAN
'kS{kf.kd _.k gsrq vkosnu&lg&ewY;kadu izi=
(PLEASE COMPLETE ALL PARTICULARS
IN BLOCK LETTERS AND TICK BOXES
WHEREEVER APPLICABLE) Signed photograph Signed photograph
of Student of Co-Applicant
¼d`Ik;k cM+s v{kjksa esa iw.kZ fooj.kh nsa rFkk ckWDl eas lgh
fpUg yxk;sa tgk¡ ekU; gks½ fo|kFkhZ dk gLrk{kfjr lg&vkosnd dk gLrk{kfjr
QksVks QksVks
CIF No. (FOR OFFICE USE)
CIF No.¼dk;kZy; O;ogkj gsrq½

ACCOUNT No. (FOR OFFICE USE)

[kkrk la[;k¼dk;kZy; O;ogkj gsrq½

(1) PERSONAL INFORMATION OF THE APPLICANT

vkosnd@lg&vkosnd dh iw.kZ tkudkjh
First Name Middle Name Last Name
izFke Hkkx e/; Hkkx vafre Hkkx
Full Name of the Student ITTEHAD ADIL
fo|kFkhZ dk iwjk uke
Full Name of Father MD WARIS
firk dk iwjk uke
Full Name of Mother AFSANA KHATOON
ekrk dk iwjk uke
Full Name of Husband (If Applicable)
ifr dk iwjk uke ¼;fn ykxw gks½
Full Name of Co-applicant AFSANA KHATOON
Lkg&vkosnd dk iwjk uke
Relationship of co-applicant with Applicant MOTHER
vkosnd ds lkFk Lkg&vkosnd dk laca/k
Address Applicant Co-Applicant
irk vkosnd lg&vkosnd
1. Address of Correspondence ALHANDA BAGHWA Kadwa ALHANDA, BAGHUA, KATIHAR
(House No. Road Name, Locality, KATIHAR,BIHAR,Pin-854317
City, Pin, District, State etc.)
i=kpkj dk irk ¼vkokl laŒ] lM+d laŒ]
eqgYyk] 'kgj] fiu] ftyk] jkT; bR;kfn½

2. Permanent Address (House No. Road Name, ALHANDA BAGHWA Kadwa ALHANDA, BAGHUA, KATIHAR
Locality, City, Pin, District, State etc.) KATIHAR,BIHAR,Pin-854317

LFkk;h irk dk iw.kZ fooj.k ¼vkokl laŒ] lM+d laŒ]

eqgYyk] 'kgj] fiu] ftyk] jkT; bR;kfn½

3. E mail address [email protected] [email protected]

¼bZesy vkbZ Mh½
4. Date of birth (DD/MM/YYYY) 30th-May-2002 1st-January-1974
¼tUe frfFk (DD/MM/YYYY)
5. Age (On Date of Application)
19 Years 3 Months 47 Years 8 Months
¼mez½ ¼vkosnu dh frfFk dks½

Application Date : 09-09-2021 1 OF 5

6. Telephone Number (Personal & Residence) Mobile ¼eks-½ 9064749193 Mobile ¼eks-½ 7739248907
nwjHkk"k la[;k ¼O;fäxr ,oa vkokl½ Residence ¼vkokl½ Residence ¼vkokl½
7. Telephone Number & Fax (Office) Institute ¼laLFkku½ 7552700400 office ¼dk;kZy;½
nwjHkk"k la[;k ,oa QSDl ¼dk;kZy; Fax ¼QSDl½ Fax ¼QSDl½
laLFkku tgk¡ vkosnd ukekafdr gks
8. Sex
P M F T M P F T
¼fyax½
9. Marital Status
oSokfgd fLFkfr P Single Married Single P Married

10.Type of identification Proof and Aadhar Card Aadhar Card

Residential proof (a) 423716193840 (a) 784912321167
¼vk/kkj dkMZ½ ¼vk/kkj dkMZ½
igpku dk izek.k i= ,oa vkoklh; izek.k i=
(b) Residence (b) Residence
Certificate Certificate
At least one document is required vkokl izek.ki= vkokl izek.ki=
for identity and one document
for address proof. (c) Voter ID (c) Voter ID
oksVj vkbZ-Mh oksVj vkbZ-Mh
¼O;fDrxr igpku gsrq ,d vfHkys[k ,oa
irk ds igpku gsrq ,d vfHkys[k vko';d gksxkA½
(d) First Page Of (d) First Page Of
Bank Passbook Bank Passbook
¼cSad iklcqd dk ¼cSad iklcqd dk
izFke i`"B½ izFke i`"B½
(e) Others (e) Others
¼ vU;½ ¼ vU;½

11.Category SC OBC SC OBC

oxZ vuq-tkfr fiNM+h tkfr vuq-tkfr fiNM+h tkfr

ST EBC ST EBC
vuq-tutkfr vR;ar fiNM+h vuq-tutkfr vR;ar fiNM+h
tkfr tkfr
General General
P lkekU; P lkekU;
12.Do your belong to minority Yes/No Yes/No
N N
D;k vki vYila[;d dksfV ls lacaf/kr gS\ gk¡@ugha gk¡@ugha
13.Required Minimum Education 10th or 12th 12th
qualification for applied course
10oha ;k 12oha
vkosfnr ikB~;Øe ds fy, U;wure
okaf{kr 'kSf{kf.kd ;ksX;rk

14.Highest educational qualification 12th

mPpre 'kSf{kf.kd ;ksX;rk

15. Are you disable Yes/No

No
D;k vki fnO;kax gS gk¡@ugha
(2) DETAILS OF THE COURSE
dkslZ@ikB~;Øe dh tkudkjh
1. Name of the Course Bachelor of Physiotherapy
ikB~;Øe dk uke
2. Name of the College/ Institution RABINDRANATH TAGORE UNIVERSITY
egkfo|ky;@laLFkku dk uke
3. Name of University to which it is affiliated RABINDRANATH TAGORE UNIVERSITY
fo'ofo|ky; dk uke ftlls lac) gS
4. Duration of course (Years) 4
ikB~;Øe vof/k

Application Date : 09-09-2021 2 OF 5

 5. Start Date of the course
September/2021
ikB~;Øe izkjEHk gksus dh frfFk
6. Date of Completion of course September/2025
ikB~;Øe lekiu gksus dh frfFk
7. Address of the College/Institution MENDUA, POST -BHOJPUR, NEAR- BANGRASIYA
CHOURAHA, BHOPAL- CHIKLOD ROAD,
Ekgkfo|ky;@laLFkku dk iwjk irk DISTRICT-RAISEN MENDUA, POST -BHOJPUR, NEAR-
BANGRASIYA CHOURAHA, BHOPAL- CHIKLOD ROAD,
8. Roll no. of applicant in institution DISTRICT-RAISEN
vkosnd dk 'kSf{kf.kd laLFkku esa Øekad

(3) LOAN REQUEST SECTION

_.k vkxzg izHkkx
1.Cost of the course and other fees (including hostel charges)
400,000
ikB~;Øe 'kqYd ,oa vU; 'kqYd ¼gkWLVy 'kqYd ds lkFk½

2.Books and stationary (As per Annexure 2 of the guideline) 0

iBu&ys[ku lkexzh ¼ekxZnf'kZdk dh vuqyXud & 2 ds vuqlkj½

3.Living expenses (As per Annexure 2 of the guideline) if hostel is not 0

available.
jgus] thou&;kiu ¼ekxZnf'kZdk dh vuqyXud & 2 ds vuqlkj½ gkWLVy vuqiyC/krk dh
fLFkfr esaA
4.Cost Of Laptop (if applicable)
ySiV‚i 'kqYd ¼;fn ykxq gks½
5.Others
vU;

A.Total 400,000
dqy

B.Funds available from other sources (scholarship etc.)

vU; lzksrksa ls miyC/k fuf/k ¼Nk=o`fr bR;kfn½
C.Total amount of loan applied for (A-B)
400,000
_.k gsrq dqy vkosfnr jkf'k

(4)BANK ACCOUNT DETAILS OF APPLICANT AND CO-APPLICANT

vkosnd ,oa lg&vkosnd ds cSad [kkrk dh fooj.kh
Applicant ¼vkosnd½ Co-applicant ¼lg&vkosnd½

Name of the Bank ¼cSad dk uke½ Punjab National Bank

Name of the Branch ¼cSad 'kk[kk dk uke½ SANKATRA

Bank Account No. ¼cSad [kkrk la[;k½ 2485001700304183

IFSC Code ¼vkbZŒ,QŒ,lŒlhŒ dksM½ PUNB0248500

(5)PROPOSED/PREFERRED REPAYMENT AND PAYMENT OF INTEREST

_.k vnk;xh ,oa C;kt dk Hkqxrku

P
Repayment by By Student/Applicant By Co-applicant By Both
vnkdÙkkZ Nk=@vkosnd ds }kjk lg&vkosnd ds }kjk nksuksa ds }kjk

Application Date : 09-09-2021 3 OF 5

 (6) DOCUMENTS REQUIRED

Mark sheet & Certificate of Class X, XII & last qualifying examination of the student
¼eSfVªd]$2 ,oa vafre lQy ijh{kk dk vadi= ,oa izek.ki=½
Copies of letter conferring scholarship, free ship, etc.(if applicable)
¼izkIr Nk=o`fÙk] fu%'kqYd f'k{kk dk i= bR;kfn½¼vxj ykxw gks½
Documents evidencing duration of course of commencement thereof, viz Prospectus or Certificate from the
competent authority of the Institution(if the University is from Bihar, then its not needed)
ikB~;Øe vof/k ds lR;kiu gsrq laLFkku ds l{ke izkf/kdkj ls izkIr ikB~;Øe foojf.kdk vFkok izek.ki=A ¼;fn fcgkj ds vanj vofLFkr
egkfo|ky; gks] rks bldh vko';drk ugha gSaA½
Proof of a admission to the course
ikB~;Øe esa izos'k dk izek.ki=
Schedule of expenses for the course
ikB~;Øe 'kqYd dh fooj.kh vuqlwph
Two copies of Passport size photograph of the student and co-applicant.
Nk= ,oa lg&vkosnd dk nks ikliksVZ lkbZt QksVksxzkQA
Aadhar card of applicant.
vkosnd dk vk/kkj dkMZA
Aadhar card of co-applicant.
Lkg&vkosnd dk vk/kkj dkMZA
First page of bank passbook(for applicant account number & bank IFSC code)
cSad iklcqd dk igyk i`"B ¼vkosnd [kkrk la[;k vkSj cSad IFSC dksM ds fy,½
Proof of residence (Residential certificate or first page of bank passbook in which address is clearly
mentioned or electricity Bill or telephone Bill or passport or Driving license or voter I.D. card
fuokl izek.k i= ¼vkoklh; izek.k i= vFkok cSad iklcqd dk izFke i`"B ftlesa vkokl dk irk Li"V :Ik ls vafdr gks vFkok
fctyh fcy vFkok VsfyQksu
fcy vFkok ikliksVZ vFkok MªkbZfoax ykbZlsal vFkok oksVj vkbZŒMhŒ dkMZ vFkok ernku gsrq iz;qDr izek.k i=ksa esa ls dksbZ ,d½A

Certificate for disability issued from competent authority.(if applicable)

l{ke çkf/kdkj ls fuxZr fnO;axrk dk çek.k i= ¼;fn ykxw gks ½

DECLARATION
?kks"k.kk
I/We hereby apply for a loan from Bihar State Education Finance Corporation Ltd. to the extent indicated in the Loan Request Section of this
application form. I/We declare that the information furnished in this application form are true, accurate and complete and that they shall form
the basis of any loan, Bihar State Education Finance Corporation Ltd. may decide to sanction to me/us. I/We confirm that I/We have/had
neither insolvency proceeding against me/us nor have been adjudicated insolvent. I/We further confirm that I/We have read the terms and
conditions and understood the contents therein. I/We am/are aware that as I/we have opted for loan at simple interest, the equated monthly
installment fixed shall comprise of principal and interest.
eSa@ge _.k gsrq _.k vkxzg çHkkx esa mYysf[kr jkf'k dh vf/klhek rd fcgkj jkT; f'k{kk foÙk fuxe fyfeVsM esa viuk vkosnu lefiZr djrk gw¡@gSA eSa@ge
?kks"k.kk djrs gSa fd vkosnu i= esa mYysf[kr fooj.k esjh@gekjh tkudkjh ds vuqlkj lgh] lVhd ,oa iw.kZ gSa ,oa fcgkj jkT; f'k{kk foÙk fuxe fyfeVsM }kjk
esjs@gekjs çek.k i= esa dksbZ _.k Loh—r fd;s tkus dk fu.kZ; dk vk/kkj xfBr djsaxsA eSa@ge laiq"V djrk@djrs gw¡@gSa fd esjs@gekjs fo:) fnokfy;kiu dk
ekeyk yafcr ugha gS ,oa u gh eq>s@ges l{ke çkf/kdkj }kjk fnokfy;k ?kksf"kr fd;k x;k gSA eSa@ge ?kks"k.kk djrs gSa fd eSus@geus blesa Hkfjr rF;ksa ,oa 'kÙkksaZ
rFkk ;kstuk dh ekxZnf'kZdk dk iw.kZ v/;;u fd;k gS rFkk mUgsa lgh rjhds ls le>kk gSA eSa@ge bl ckr ls voxr gw¡@gS fd ;fn eSa@ge fcgkj jkT; f'k{kk
foÙk fuxe fyfeVsM }kjk fu/kkZfjr C;kt ,oa fdLr ds nks ?kVd ewy/ku ,oa C;kt gksaxsaA
I/We agree that Bihar State Education Finance Corporation Ltd. may at its discretion conduct discreet inquires in respect of this application.
I/we undertake to inform as to any change in my/our occupation/employment, residential/official address and to provide any further
information that District Registration and Counseling Center and Bihar State Education Finance Corporation Ltd. may require. Bihar State
Education Finance Corporation Ltd. will be at liberty to take such action as it may deem necessary if my/our above statements are found to be
untrue. I/We agree that Bihar State Education Finance Corporation Ltd. shall have the sole discretion to reject our loan application or reduce
loan amount without any reason. I/We further agree that my/our loan transactions shall be governed by the rules of Bihar State Education
Finance Corporation Ltd. which may be in force from time to time.

eSa@ge lger gw¡@gSa fd fcgkj jkT; f'k{kk foÙk fuxe fyfeVsM vius foosdkf/kdkj ds vk/kkj ij vkosnu esa of.kZr rF;ksa dh foosdiw.kZ tk¡p djkus esa l{ke gSA
eSa@ge opu nsrs gSa fd esjs@gekjs jkstxkj/fu;kstu] vkoklh; irk esa ifjorZu dh fLFkfr esa eSa@ge ftyk fuca/ku ,oa ijke'kZ dsUæ rFkk fcgkj jkT; f'k{kk foÙk
fuxe fyfeVsM dks lwfpr djsaxs vFkok fcgkj jkT; f'k{kk foÙk fuxe fyfeVsM }kjk ;kfpr dksbZ vU; lwpuk çek.k i= ;k dkxtkr Hkh miyC/k djk,axsA fcgkj
jkT; f'k{kk foÙk fuxe fyfeVsM çLrqr dFkuksa dh vlR;rk dh fLFkfr esa fcuk dkj.k crk, _.k jkf'k dks jí vFkok de djus gsrq Lora= gksxkA eSa@ge bl ckr
ls lger gSa fd _.k jkf'k dk ysu&nsu fcgkj jkT; f'k{kk foÙk fuxe fyfeVsM ds le;≤ ij ykxw fu;eksa ds vk/kkj ij gksxkA fcgkj jkT; f'k{kk foÙk fuxe
fyfeVsM ds ikl vkosnu dh vLoh—fr dk vf/kdkj lqjf{kr gksxkA

Application Date : 09-09-2021 4 OF 5

 Signature of the student Signature of the CO-Applicant
Place.... Place....
Date... Date...
lg&vkosnd dk gLrk{kj
fo|kFkhZ dk gLrk{kj
LFkku% LFkku%
frfFk% lg&vkosnd ds vkfFkZd fLFkfr dh fooj.kh frfFk%
vkosnd dh ?kks"k.kk
1- eSa viuk vk/kkj la[;k lefiZr djrk@djrh gw¡ ,oa LosPNkiwoZd lgefr nsrk@nsrh gw¡ fd ;wŒvkbZŒMhŒ,ŒvkbZŒ Hkkjr ljdkj }kjk fuxZr vk/kkj@;wŒvkbZŒMhŒ la[;k dks esjs uke
ls la/kkfjr vkosnu ds lkFk tksM+k tk;A
2- bls ,uŒihŒlhŒvkbZŒ ¼us'kuy isesaV dkjiksjs'ku v‚Q bafM;k½ esa ntZ fd;k tk,] rkfd ljdkj }kjk izR;{k ykHk varj.k ¼MhŒchŒVhŒ½ ;kstuk ds rgr ykHk esjs mDr cSad
[kkrk esa izkIr gks ldsA
3- ;wŒvkbZŒMhŒ,ŒvkbZŒ }kjk iznÙk vk/kkj la[;k dks esjh igpku dks izekf.kr ,oa LFkkfir djus esa mi;ksx fd;k tk;A
4- fcgkj LVwMsaV ØsfMV dkMZ ;kstuk gsrq vkosnu lefiZr djus ds fnu esjh vk;q 25 o"kZ ¼dqN ekU; dkslZ ds fy, 30 o"kZ½ ls vf/kd ugha gSA
5- esjs }kjk miyC/k djkbZ xbZ lwpuk dk mi;ksx ukfer ckg~; tk¡p ,tsalh ¼Vh fi fo ;s½ }kjk lR;kiu gsrq fd;k tk ldsxkA
6- esjs }kjk vkosnu esa vafdr eksckbZy la[;k dks ,lŒ,eŒ,lŒ vyVZ gsrq mi;ksx esa yk;k tk ldsxkA
7- esjs }kjk bl ;kstuk dh ekxZnf’kZdk ,oa le;≤ ij fuxZr la'kks/kuksa dk v/;;u dj fy;k x;k gSA
8- eSa lgefr nsrk@nsrh gw¡ fd vk/kkj la[;k ds ckjs esa esjs }kjk tks mi;qZDr lwpuk miyC/k djk;h x;h gS] mls mi;qZDr dk;Z ;k dkuwuh t:jrksa ds vfrfjDRr vU;Fkk mi;ksx esa
ugha yk;k tk;xkA

LFkku %&

frfFk %& vkosnd dk gLrk{kj

egÙoiw.kZ vuqns'k
vkWuykbu vkosnu tek djus ds i'pkr vkosnu esa nh xbZ lwpuk ds lR;kiu.kksijkar ftyk fuca/ku ,oa ijke'kZ dsUæ ¼Mh-vkj-lh-lh ½ }kjk ftyk fuca/ku ,oa ijke'kZ dsUæ ij
vkus dh frfFk ,oa le; b&esy rFkk ,l e ,l }kjk lwfpr dh tk,xhA fcgkj LVwMsUV ØsfMV dkMZ ;kstuk gsrq bPNqd ;qokvksa dks ftyk fuca/ku ,oa ijke'kZ dsUæ ij vkosnu
tek djrs le; vius LogLrk{kfjr vkosnu i= ds lkFk fuEufyf[kr dkxtkrksa dh ewy&çfr ¼ewy&çfr LdSu djus ds mijkar rRdky okil dj fn;k tk;sxk½ ,oa
Lo&vfHkçekf.kr Nk;kçfr layXu djuh gksxh &
¼d½ vkosnd ,oa lg&vkosnd dk vk/kkj dkMZA
¼[k½ eSfVªd $2 ,oa vafre lQy ijh{kk dk vadi= ,oa çek.k i=A
¼x½ çkIr Nk=o`fr] fu%'kqYd f'k{kk laca/kh çek.k&i= bR;kfn ¼;fn ykxw gks½A
¼?k½ ikBîØe vof/k ds lR;kiu gsrq laLFkku ds le{k çkf/kdkj ls çkIr ikBîØe foojf.kdk vFkok çek.k i= ¼fcgkj ds vanj vofLFkr egkfo|ky; esa bldh vko';drk ugha gS½A
¼M+½ ikBîØe esa ços'k dk çek.k i=A
¼p½ ikBîØe 'kqYd dh fooj.kh vuqlwphA
¼N½ Nk=@ekrk&firk@vfHkHkkod@lg&vkosnd dk nks ikliksVZ lkbZt QksVksxzkQA
¼t½ fuokl çek.k i= ¼vkoklh; çek.k i= vFkok cSad iklcqd dk çFke i`"B ftlesa vkokl dk irk Li"V :i ls vafdr gks vFkok fctyh fcy vFkok VsfyQksu fcy vFkok
ikliksVZ vFkok MªkbZfoax ykbZlsal vFkok oksVj vkbZŒMhŒ dkMZ vFkok ernku gsrq ç;qä çek.k i=ksa esa ls dksbZ ,d½A
¼>½ fdlh vuqlwfpr cSad esa vkosnd ds uke ls la/kkfjr cSad iklcqd dh çFke i`"B dh Nk;kçfr ftlesa vkosnd dk uke] irk] cSad [kkrk la[;k rFkk lacaf/kr cSad 'kk[kk dk vkbZ
,Q ;l lh dksM Li"Vr% vafdr gksA

DRCC KATIHAR
ftyk fuca/ku ,oa ijke'kZ dsUæ ---------------------------------
(8) ADDITIONAL DETAILS OF BANK ACCOUNT OF THE CO-APPLICANT
ITTEHAD ADIL
Jh@Jherh@lqJh ------------------------------------------------------------------------------------------------------------- ls fcgkj LVwMsUV ØsfMV dkMZ ;kstuk gsrq fnukad ---------------------------------------------------------------------------------------
CM7RBSCC092021004001975
dks lHkh okafNr vuqyXudksa lfgr vkosnu i= izkIr fd;kA ftldk fuca/ku la[;k -------------------------------------------------------------------------------------- gSA
izkIrdÙkkZ dk iw.kZ gLrk{kj &
uke&
inuke &
fnukad %&
uksV & vkWuykbu vkosnu djus ds 180 fnuksa ds vanj fdlh Hkh dk;Z fnol ij t:jh izek.k i=ksa ds lkFk ftyk fuca/ku ,oa ijke'kZ dsUnz ¼Mh -vkj- lh -lh ½
igq¡p dj çek.k i=ksa dk lR;kiu djokuk vfuok;Z gSA lR;kiu ugha djk, tkus dh fLFkfr esa vkosnu Lor% jí gks tk,xkA
fdlh Hkh izdkj dh tkudkjh@lgk;rk gsYiykbZu ucaj 1800 3456 444- ls izkIr fd;k tk ldrk gSA

Application Date : 09-09-2021 5 OF 5