PART-I

LOAN APPLICATION FORM

(Basic Information common to all Schemes)

To,
THE BRANCH MANAGER
CENTRAL BANK OF INDIA

I/We request for a loan of Rs 50,00,000.00 under Education Loan for MBA from Premier
Management Institutes.

I/We furnish our particulars as below.

APPLICANT JOINT-APPLICANT
NAME (in block letters) SUMIT KUMAR DAS

PAN Number EGBPD7078C

Fathers/Husbands Name CHITTARANJAN DAS

Relationship with FATHER

Co-Applicant / Applicant
Residential Address 601/4 , F1 Block , IIM Ranchi ,
Present Address: Ranchi , Jharkhand

Period of stay at the above LAST 24 YEARS

Address
Tel No.: N/A
Mobile No.: 8789826717
E Mail: [email protected]
Permanent Address: VILLAGE – BAGHAR, POST –
BALRAMPUR, DIST -KATIHAR,
STATE -BIHAR

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Residentail Status Resident Resident/Non Resident
AGE 26
DATE OF BIRTH 17/11/1997
SEX MALE

MARITAL STATUS UNMARRIED

OBC
You belong to:
Children – Nil
No of Dependants
Others – Nil
Educational/Professional MBA
Qualification
DETAILS OF OCCUPATION / PROFESSION / BUSINESS
PARTICULARS
Name of Employer/ Nil
Nature of Business/Profession
Address with telephone number NA
of Employer
/Business/Profession
If employed Designation and NA
Employee number
No of years in present NA
occupation/Business/profession
Length of service NA
Date of Retirement NA

INCOME STATEMENT
Gross salary/Income per month Nil
(salary sheet / I.T. Return, form
No.16 attached)
Deductions Income Tax
Professional Tax
Provident Fund
Insurance Premium
Other statutory deductions
Net Salary / Income p.m.
Other Income if any
(Proof Attached)

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DETAILS OF BANK ACCOUNTS
Name of the Bank/Branch

Type/s of the Account

Account Number/s

Since When
Average credit balance for last 6
months

DETAILS OF EXISTING LOAN FROM CENTRAL BANK/OTHER BANKS

Name of Bank/Branch Nil

Type of Loan Availed

Amount of loan Availed
Present outstanding
Security Offered

Repayment Plan
Amount of Default if any

DETAILS OF OTHER LIABILITIES

Loans from Employer. Nil
Loans from friends/liabilities.
Materials/Assets purchased
from the seller on credit.
Other liabilities.

IF CREDIT CARD HOLDER/S DETAILS OF CREDIT CARD/S

Name of Issuing Bank/Agency Nil
Credit Card number
Expiry Date
Credit Limit
Present O/S Amount

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DETAILS OF ASSETS
Nil
Cash
Deposits with Bank Nil

Immovable assets/Properties Nil

With address & value

Movable assets

Investments (Specify each) Nil

Others
(Please specify)
TOTAL Nil

DETAILS OF COLLATERAL SECURITY OFFERED:

Description of Property Owner of the Property Value of Property

(With full Postal Address)

NIL

DETAILS OF COLLATERAL SECURITY OTHER THAN PROPERTY

NIL

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GUARANTOR/S:(Attach Guarantor’s Consent letter)

Name Guarantor-I Guarantor-II Guarantor-III

Address

Occupation NIL
Net worth
Amount of
guarantees
already given

PROPOSED PERIOD OF REPAYMENT

(3 years of Moratorium+15 Years) = Total 18 years

I/we declare that all the particulars and information given in the application /annexure are true, accurate,
complete and up to date in all respects and I/We have not withheld any information and same shall form
the basis of the loan Central Bank of India may consider to me/us. Bank is at liberty to take any such
action as it may deem fit if my/our statements are found to be untrue. I/We confirm that the funds will
not be used for speculative/illegal or anti social purposes. I/We confirm that I/we had no insolvency
proceedings against me/us nor have I/We ever been adjudicated insolvent. I/We agree that my/our loan
shall be governed by rule of Central Bank of India, which may be in force from time to time. The Central
Bank of India reserves the right to reject the loan application without providing any reason. I/We
authorize Central Bank of India or its agents to make references and enquiries relative to the
information in the application which Central Bank of India consider necessary. I/We undertake to inform
Central Bank of India regarding change in my/our residence/employment and to provide any further
information that the bank may require. I/we understand that certain particulars given by me/us are
required by the operational guidelines governing Banking Companies. I/we authorize Central Bank of
India to exchange, share, or part with all the information relating to my/our loan details/repayment
history / information to other Central Bank branches / Banks / Financial Institutions / RBI / CIBIL / Credit
Bureau / Agencies / Statutory Bodies as may be required and shall not hold Central Bank of India or/&
its agents liable for use of this information. Central bank of India reserves the right to retain the
photographs & documents submitted with this application and will not return the same to the applicant/s.
I/We also declare that I am/we are not related to any director of the bank or any other Bank. I/We
confirm that I/We have not defaulted in repayment of loan taken from your bank/other banks nor
entered in to compromise settlement as borrower/guarantor.

Place: Katihar Signature of the Applicant

Date: 05-06-2024 Signature of the Joint-Applicant

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 PART-II
CENT VIDYARTHI
(For Common Application Form,Guarantor’s Consent Letter & Acknowledgement-Please fill PART-I.)
BASIC INFORMATION

Sl Particulars Details
a. Proposed course of Study MBA

b. Duration of Course Years Full time Part time

2 Yes No
c. Name and address of the College / IIM RANCHI
Institution in which the student intends
to join.

d. Name of the University/Recognised IIM RANCHI

Authority to which the college/
institute is affiliated.

e. Has the student been admitted into the Yes

above College /Institute / University
or accepted for the Course? If so,
certified copy of admission/
acceptance Letter should be attached
f. Is the applicant attending any college No
or Institute at present? If so, furnish
full particulars.
g. No. of earning members in the Family 1 , Income – 4,00,000
& their total income.
h. Whether the student has any working Yes, Cipla Limited , Mumbai
experience? If yes, please give details.
i. Whether the student will take up any No
part-time employment during study? If
yes, please give details.
i. Year of retirement of father Guardian 2034
(if in service only)

…2
..42..

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.

CENT VIDYARTHI
STUDENTS ACADEMIC RECORD:
Name of the examination from SSC or equivalent onwards
SSC HSC B.E.(Chemical) MBA
Name of the SCOTTISH SCOTTISH JADAVPUR IIM
School/ College PUBLIC PUBLIC UNIVERSITY RANCHI
SCHOOL SCHOOL
Medium of ENGLISH ENGLISH ENGLISH ENGLISH
instruction
Examination CBSE CBSE JADAVPUR IIM
authority BOARD BOARD UNIVERSITY RANCHI
Month & year of 2013 2015 2020 2025
passing
Whether passed in Yes Yes Yes NA
the first attempt
Aggregate marks 475 455 787.3 NA
first attempt
Out of total marks 500 500 1000 NA
Percentage of 95 91 78.73 NA
marks
Rank/Class/Div 1st Division 1st Division 1st Class with NA
obtained Distinction
Scholarship/ Yes Yes No NA
Prizes won for
academic
distinction.
(Certified copies of the list of marks of all the above exams should be enclosed)

PARTICULARS OF FINANCIAL REQUIREMENT OF THE COURSE

Studies in India Amount in Rs. Studies in abroad Amount in Rs
Admission fee Total fees for ______ per year
Term Fee for 2 years 8,55,000 Books, stationery, instrument
& equipment
Boarding & lodging @ NA Boarding & lodging @
Rs.______ per month ___________ per year for
for _______ _____________ years
Other Charges Other charges
Mess Charges 81,000
Personal Expense 0
Insurance 00
Laptop 00
Study Tour/Project 0 Total i.e. Equivalent in Rs.
work/Thesis work

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Visit to foreign 0
university in exchange
programme
Total (enclose 9,36,000 Air passage (one way only)
evidence)
Total (enclose evidence) 9,36,000

..43..

CENT VIDYARTHI
SOURCE OF FINANCE:
1. Non repayable scholarship(s) at Rs. __________ p.a. for
____________ years
2. Loan scholarship(s) and or other repayable financial assistance
from other sources
3. Contribution of Parent/ Guarding and /or other Members of
the family / relatives towards total expenses
4. Amount of loan required from the bank
5. Earning of the student (if any)
Total

Particulars of Insurance Policy (ies) (In the case of father/ guardian/ applicant only)
Names of the insured Policy No Date Date(s) of Amount of Date of last
Maturity yearly premium
premium paid

ADDITIONAL INFORMATION TO BE FURNISHED BY STUDENTS UNDERTAKING

STUDIES ABROAD
a. Amount of foreign exchange required.
b. Foreign currency
c. Rupee equivalent
d. Have you obtained the necessary passport,
/visa etc? Yes/No.(if yes, give reference)
e. Do you intend to take up any part time
employment during the course of studies
abroad? If so, give particulars.
f. What are your likely Prospects on your return
to India?

DECLARATION: We hereby declare that the information furnished against the foregoing
items is true to the best of our knowledge and belief.

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 We also undertake to inform the bank immediately any change in our
employment details, address, telephone number including mobile no. etc. for both local and
permanent address,

Signature of Father/Guardian

Place - Katihar Signature of student Sumit Kumar

Das

Date – 06th June, 2024 Signature of Guarantor (if any)

ASSET & LIABILITY DECLARATION

MR/MRS–
*

LIABILITIES Amount ASSETS Amount

BORROWINGS FROM DEPOSITS WITH BANK
EMPLOYER
BORROWINGS FROM POSTOFFICE DEPOSITS
BANK/FINANCIAL
INSTITUTIONS

1.Central bank of India

2.

OTHER LIABILITIES( PLZ NSC/KVP/PPF/LIC

SPECIFY)
1.Sundry Creditors

2.OCL

NET OWNED FUNDS/ SHARES/DEBENTURES/BONDS

CAPITAL
GOLD & JWELLERY
INVESTMENT IN BUSINESS
IMMOVABLE PROPERTIES(DETAIL
ADDRESS)

VEHICLE
(2/4 WHEELER)

OTHER ASSETS (PLZ SPECIFY)

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 FD AND RD

TOTAL Nil TOTAL Nil

SIGNATURE----SUMIT KUMAR DAS----- ----------------

(NAME OF APPLICANT)
DATE:-

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