Balageria Central Co-operative Bank Ltd.

Head Office : At – Contai, Dist. – Purba Medinipur

Email : ho@balageriabank.com :: 03220-254421
No.:

Application form for Membership in getting Additional Pension Scheme

1. Applicant’s Name : (with

Employee ID) :

2. Father’s / Husband’s Name :

3. Residential Address : At – P.O. -

(as per Aadhaar Card) P.S. – Dist. -
Pin -
4. Corresponding / Present At – P.O. -
Address :
P.S. – Dist. -
Pin - Ph./M. No. -

5. a. Date of Birth :
b. Age (as on 01-01-2023) :
6. a. Aadhaar No. :
b. Pan No. :
(Please enclose herewith)
7. Details in regards to Service &/or Superannuation :
a. Date of Joining in Service :
b. Date of Retirement from Service :
c. Rank / Position held at the time of retirement
from Service :
d. Present Monthly Pension received :
8. Bank Account Details :
a. Savings A/c lying at Balageria Bank :
i) A/c Number : ii) Branch Name :
iii) Amount of Deposit :
b. Savings A/c &/or Pension A/c lying at (other Bank) :
i) Bank Name with Branch : …………………………………………………………
ii) Amt. of Deposit : …………………………………………
9. Whether any legal cases being undertaken as against the Bank or not (yes / no) :

I do hereby declare that all above facts and information are true & correct to the belief of my
knowledge.

Dated …………………… Applicant’s Signature

[Note : Eligibility for Membership : A person shall be eligible to become a member of the Scheme
provided he / she is in regular full time employment and remains as Employee of the Bank and
includes the alive retired employees on & from 01/04/2000.]

For Office Use : No.

Date : Signature of Authorised Officer