o J . CIN: U65999KA2022PLN157893 | Regd. with M.C.A., Govt. of India a njyeeva D1 @wwwivabanking.com @ info@jvnbanking.com 7996655579 VIKAS NIDHI (BANK) LTD Registered Office: Rs. No. 974/K, Plot No. 45, Satti Road, Near 4th nseeeseene® Cross Church, Left Side Athani, Belgaum 591304 Karnataka, India For Member ID: Office Use Share Folio No. Please fill the Form in English and In BLOCK Letters. Tick ¥ wherever applicable, Application Type: New Update = §ERDOR000 To, The Board of Directors, Janjeeven Vikes Nidhi Limited, I hereby apply for the membership of the company. [ender a sum of 2100/- for 10 share(s) each of value €10/- and | will abide by the present rules & regulations and Memorandum of Association and Articles of Association of the company and changes, modifications and amendments made there to under the Section 406 of Companies Aci 2013 and Companies (Nidhi Companies) Rules, 2074, from time to time, | solemnly declare that | am not @ member of any other company similar in nature of “Janjeevan Vikas Nidhi Limited”. However, all information provided by me in the application form is true and correct to the best of my knowledge. My detailed particulars are as following FulName Father's/Husband’s Name Mother's Name Date of Birth ‘Aadhaar No, Stte/UT. Residence Type Owned _—Renfed/Leated —Ancestal/Parenfal Company Provided Other Permanent Address Same as communication address Please note the address below District swt | oi Residence Type Owned _—_Renfed/Leated ——Ancestal/Parenfal Company Provided Other ‘Occupation: Salaried = Selfemployed Professional —=Refired Other Income per Annum (2) GSLAKH —«-SIOLAKH.—=TO-SLAKH.=—=S-25 LAKH «25-50 LAKH > 50 LAKH Educational Qualification Below 10th Matriculate «Graduate. -—=—~Post Graduate Professional —_—ilterato DECLARATION BY APPLICANT I hereby declare that | voluntarily opt to be a member in Janjeovan Vikas Nidhi Limited & shall abide by the existing rules & regulations of the company & also the amendments as may take place from time fo time, The declaration is made by me is correct & | have been explained everything related to the membership in language known fo me. Date: > / / Place: —— Signature of ApplicantMembership Application Form GE conics ofthe documents one for and proce he agi copes of hose documents fo wsfton Ihave attached copy of as Proof of Kdentiy & copy of, 1s Proof of Address, hime) | declare Mr /Miss./Mrs. as the nominee of the share(s) purchased by me, He/She is my. (Relationship). His/Her age in years, In case the nominee is a minor, his/her Guardian's Name Signature of Applicant The terms and conditions related to the membership have been explained to me in language, by Mr /Miss /Mrs, nl }, and I declare that | have understood and consented to all the terms and conditions and also to the declarations and undertakings and | agree to abide by the same. Signature of Applicant | confirm hat, | have explained the terms and conditions of membership to the applicant in vernacular language known fo him/her ‘and the applicant affited the above signature in my presence. Signature & Employee ID of the Company Official: — CR FE USE ONY $$ Receipt no. has been issued to applicant on date against payment forthe requested share) Verifcstion by Employee Management Remarks | hereby declare thal this Membership cum Share Application Form is complete in all respects and. relevant documents have been obtained, verified and signature is Janjeevan Vikas Nidhi Lid. has ( ) Accepied / ( ) Rejected biained in physical presence ofthe applicant Company Management / Membership Committee of this application on Emp, Name: p. Nat Membership ID if accepted Emp. ID: Date: / Remarks if rejected Signature of Employee Director/Authorized Signatory (GENERAL INSTRUCTIONS / T&Cs (FOR MEMBERSHIP OF JANJEEVAN VIKAS NIDHI LIMITED) 1. Appa hat to tch st cpy of aes ary proof wih Mambarship cum Share Applcaten Form Lit of cape Doct Proof f Wonty and Proof f Ades td ‘A Pt of Wey (ny ooo to folbw ng 1} Paspor i] Unque Wanifeaton Nbr, () lzonee PAN cad i cee Peto Ky Cad) Diving lance, anon cod 5. Proof of eden anyone th allowing! Peston i Una anton Nana i Hes Pts Karty Cad Oren hence, baton crs, lesa {a Bk scout strat, fs) Elect Bl cures read orl nr i, ia i abo ean ba more an wo mons o 2 Arinor shal nat bo ated a 3 monbur; Povaod ha depos may be cet nanan of amie, ey 2 mada by ho nal gal guar whos 2 monbr of Conny 8 ecw appear i sb an ret slg, depos cco needs © be opened non nne=ip 4 Thelin ane all formensonh nthe Company 5. Amenburcan seal Savings Acourcuring Depi/Tarm Dapost en ler dapost scares inthe Compa. 6. Amenber can alban on Gol she & only / nl pope / FD. recap, Naloal Senge Ceri, cher Gon Secutir&inwance poles om e Conpary. 7 Thereby supe conser and ashoras he Company orate spore cle sd sna Mx andor ena inform re on any formato o apa reaing Toe Companys ang / ne erodude/ saves The sod conser ghar ewes Meche tine ane ing. Bal dspace hllbs eoarosby Lave o ha an all bs jc uk juan of he au Balsam, Kara Date: / Place: Signature of Applicant