APPLICATION FOR EMPLYOMENT

To, Please affix your

recent
HR Manager
photograph here.
Midland Microfin Limited Application
The Axis, Plot No.1, RB Badri Dass Colony, without
G.T. Road, Jalandhar. photograph is
invalid.
Dear Sir / Madam
Subject: Application for the position of .
I am writing this with your job requirement for the position of . I truly believe that my
qualifications and experience make me a suitable candidate for the job. My personal and professional details have been appended below for your kind
consideration:

(1) Personal Details:

Name Gender Male / Female Date of Birth

Marital Status Single / Married / Religion Sikh / Hindu / Muslim / Caste SC / ST / OBC / General
Divorcee / Separated Christian

Mobile No. Emergency Email Address

Contact no.

Two Wheeler Yes / No Driving Yes / No Aadhaar Number

License

Pan Card No. Voter ID Nationality Indian

Card No.

Blood Group Reference Relation with

given by reference

(2) Current & Permanent Address Detail:

Particulars Current Address / Address for Permanent Address

Communication

House No.
Village / City / Ward No.

Tehsil

District

State

Pin code

(3) Family Details:

Name Age Qualification Occupation Relation Mobile No.

Father
Mother

Wife / Husband (If

married)
Sister/Brother – 1

Sister/Brother – 2

Son / Daughter
 Son / Daughter
Father in – Law (For
married females)
Mother in – law (For
married Females)
Brother in Law
Sister in Law
(4) Qualification Details:

Examination Stream Percentage Name of Board / Year of Regular / Subject

Passed College / University Passing Correspondence
School

10th
12th
Diploma
Graduation
Post -
Graduation
Certificate
Course

Other (if any)

*Stream refers: - Arts/Science/Commerce/Business Administration/Engineering/Computer Science.

(5) Computer Proficiency: Excellent / Very Good / Good / Average / Poor

(6) Work Experience

Name of Job Last Profile Date of Reason of Date of Cash in Total CTC
Company Location Designation Joining leaving Relieving hand
Held

(7) Present Remuneration (Please do attach latest 3 salary slip & Bank statement of last 3 months)

Monthly Cash in Hand Other Reimbursement

Cost To Company Expected Salary

(8) Have you had any promotion within your current organization? Yes / No
If yes, then please specify

(9) Minimum notice period (in months) required before joining:

 (10) Professional Reference:

Particulars Name of Organization Designation Mobile Number Shall contact for

Reference ref. check

Yes / No
Yes / No
Yes / No
Yes / No
*Current employer will be approached after the proposal is being accepted by the candidate.

(11) Reference of Two persons (Should be any Sarpanch / Panch / Mukhia / Ward member) and prominent person of
Locality other than blood relatives or friend)

Name Relation Occupation Organization Mobile No. Address E Code (If

working In
MML)

(12) Have your family members (mother/wife/sister) has taken loan from MML? If yes, please provide following details:
(Yes / No)

Name of Borrower Relation Village Center No. / Loan Amount Loan Outstanding
Group No. Amount

(13) Details of Relatives working in Midland Microfin Limited:

Name [Link] Designation Location Relation Working since

(14) Language Known

Language Known Speak Write Read

English Yes / No Yes / No Yes / No
Hindi Yes / No Yes / No Yes / No
Punjabi Yes / No Yes / No Yes / No
Other Yes / No Yes / No Yes / No
Other Yes / No Yes / No Yes / No
 (15) Training / Seminar Attended (if any)

Training / Seminar Title Institute From Date To Date

(16) Do you know anyone in our company? Yes / No

(17) Have you been interviewed by us before? Yes / No

If ‘yes’, then for ‘what post’ and ‘when’?

(18) Kindly share the name & profile of those people who will act as on ‘Guarantor’ for you?

Name of Relation with Department Designation Working since Salary

Guarantor Candidate

*Guarantors should be preferably from State / Centre Government job (except Policeman, Advocate, Lawyer, Press Reporter) or
from Limited companies having monthly salary more than 15000/- monthly.

(19) What do you know about Microfinance?

(20) Why do you want to join Midland Microfin Limited?

(21) Do you understand the profile you have applied for? Kindly describe?

(22) Do you think that you are suitable for the profile you have applied for?

(23) Are you mentally and physically ready to do field work within working area of company? Yes / No

(24) Are you mentally and physically ready to work among our members in field? Yes / No

(25) Will your family support you for this job? Yes / No
(26) Would you like to undertake to serve for at least 2 Years? Yes / No

(27) Are you suffering from any disability or had any critical illness/medical history? Yes / No
 (28) Have you ever been convicted for any criminal offence? Yes / No

(29) Have you ever been subjected to any disciplinary proceedings by your previous employer? Yes / No

(30) Have you ever been exposed to prohibited drugs? Yes / No

Declaration of Applicant:

I hereby certify that all the above information given in this application is true to the best of my knowledge. Should any
information stated by me in this application be incorrect, my employment with you is liable to immediately termination
without payment of any compensation thereof. Should there be any changes in the particulars given by me in this application,
I shall immediately inform the HR department about the same.

Yours Truly,

Date: Signature of Applicant

CONSENT / AUTHORIZATION FORM

I Mr./Ms. S/o or D/o , aged about yrs., having PAN No. or

Aadhaar No. , hereby agree that in connection with my employment with Midland Microfin Ltd., I
will be subject to background verification, as deemed necessary by Midland Microfin Ltd., or its representatives and I hereby
authorize and provide my consent to Midland Microfin Ltd., and also to its representative namely Equifax Analytics Pvt. Ltd.
(“Equifax”), to verify all the information provided by me including but not limited to my personal information and Sensitive
Personal Data or Information, which is already available with Equifax and further authorize Equifax to use the same to generate
and deliver the Verification Report to Midland Microfin Ltd..

Signature:

Name in Capital Letters:

Date:

Mobile No:
 Annexure : Staff Undertaking

Employee Code:- Designation:

I, S/O / D/O , DOB ,

Resident of

Do hereby affirm on oath that:

The information regarding my academic qualifications, family background, work experience (if applicable)
mentioned in my application form is true to my knowledge and is accurate record of my education
and employment.

I have neither been convicted for any criminal offence in any legal proceedings by competent court of law,
nor I have been involved or held guilty in any disciplinary issue / misconduct/fraud/embezzlement of cash,
in my previous employment.
I have never been exposed to any prohibited drug.

I declare the above statements to be true in all respects. I acknowledge that any statement, which is found
to be false or deliberately misleading, may make me liable to terminate without any prior notice.
I further declare and undertake that

I have familiarized myself with my key responsibility and key policies of Midland Microfin Ltd.
I undertake that I will carry out responsibilities with care, diligence and thoroughness, according to
my job description and the Operation Manual and will obey staff and office rules.
I undertake to supervise subordinate staff (if any) systematically and thoroughly to ensure that
instructions given are actually carried out, and in ways consistent with the procedure and
internal controls outlined in the various manuals of Midland Microfin Ltd.
I undertake to be honest and sincere in all my work, to set a good example so as to build the
public image of Midland Microfin Ltd. and to do nothing that would detract from its goodwill.
I undertake to assist in whatever ways I can, to realize company vision and mission.
I undertake not to disclose any confidential information or knowledge concerning the business
of Midland Microfin Ltd. to any third party.
I understand that any material violation of the undertaking will be deemed to be misconduct &
will result in punishment as per rule of Standing Orders of Midland Microfin Ltd.

Yours Sincerely

Name: Signature: Date:

 Declaration : Familv Loan

R/o
declares that my

family member/members “have taken”/ “not taken” loan from Midland Microfin Ltd.

In case of “have taken”:- I hereby declare that I will close the loan account within 2 months from my joining.
The loan details are as follows:

Particulars Details Details

Member ID Centre ID

Member Name Relation with Member

Loan From Branch TotalLoan

Installment Amount Total No. of Installment

No. of Installment Paid No. of Installment

Due
Loan Purpose Total Outstanding

Family Members to be considered are as follows:-

0 Mother Including Step Mother

0 Mother In Law
0 Daughter in Law (Son’s Wife)
0 Daughter including Step
Daughter O Brother’s Wife
O Brother’s Wife Daughter
O Sister Including Step
Sister O Sister’s
Daughter
O Cousin
O Sister in Law

Yours Sincerely

Name: Signature: Date:

 Declaration : Group Mediclaim Insurance & Personal Accidental
Polic

Employee Code: Employee Name:

Designation: Father Name:
Address:-

Group Mediclaim Insurance Policy

I hereby undertake that I have taken the clarity regarding Group Mediclaim Insurance Policy of
the
Company. The details of my family members are as follows:-

Name of the family member Relationship Date of Birth Nominee

Self

Spouse

Son/Daughter

Son/Daughter

Group Personal Accident Policv

In case of my death (or any other mishap), I request you to provide the insurance coverage amount to
the nominee mentioned below: -

Name of the Nominee Relationship Age Permanent Address (with pin code)

I understand that this undertaking is irrevocable and applicable for the payment of premium amount by the
company during my service period with the company further undertakes to inform the company as and
when there is change in the name of the nominee. Till the submission of the change in writing there will be
no change of nominee.

Yours Sincerely

Name: Signature: Date:

 ESIC Declaration Form

This is to declare that I S/o / D/o

R/o

is “a member” of / “not a member” of, ESI.

In case of “a member”:-I hereby declare that I am a member of ESI (Employee State Insurance). The
previous employment details are as follows:-
Particulars Details Particulars Details
ESI Number Name of the Company
Date of Exit from
Aadhar Card Number
Previous Company
Note: I will inform the company if there will be any change in my family.

In case of “not a member”:- I hereby declare that I am not a member of ESI(Employee State Insurance).
The details of my dependent family members are as follows:-
Name of the family member Relationship Date of Birth Nominee
Self
Spouse
Son/Daughter
Son/Daughter
Father
Mother
Note: I will inform the company as and when there will be any change in my family.

Nominee:
In case of my death (or any other mishap), I request you to provide the insurance coverage amount to
the nominee mentioned below:-
Name of the Nominee Relationship Age Permanent Address (with pin code)

I understand that this undertaking is irrevocable and applicable for the payment of premium amount by the
company during my service period with the company further undertakes to inform the company as and
when there is change in the name of the nominee. Till the submission of the change in writing there will be
no change of nominee.

Yours Sincerely

Name: Signature: Date:

 Form No.- 1 1 — Declaration Form
f <' c « t• ine d by I he employer )or fu ture r eference)
E MPLOY EES’ PROVII3E NT FUND ORGANISATION
Employees' Provident Fund* Scheme, 1952 (Paragraph 34 & 57) 6
Emp!OY ' Pe0*on Scheme. 1895 (Paragraph 24)
(Dedaraticr by a person taking up employment in any establishment on which EPF Scheme, 1952 and /or EPS, 1995 Is applicable)

Name of the
rnembc'r

2 Father’s Name Spc›use's Name

(Please tick whichever is applicable)
3. Date of Birth: ( DD / MM / YYYY )
4 Gender: (Nala /FemaIe/Transgender)
5 Marital Status. (Mari ied/Unmarried/Widow/Widower/Divorce=')
6 (d) Email ID: ” """ “”
(b) Mobile Nc .:
Whether earIi‹*r a member of Employees’ Provident Fund Scheme, Yes /•ftIo
1952
8 Whether earlier a member of Employees’ Pension Scheme, 13a.S Yes / do
Previous employment details: [if Yes to 7 AND/ OR 8 itbove]
a) Universal AccoL:nt Number:

b) Previous PF Account Number:

9
c) Date of ecit from previous employment: (DD/MM/YYYY)
d) Scheme fJert‹ficate No. (it issued)
e) Pension f’aymeilt Order (PPO) No. (iF issued)
a) lnternati‹›nal Worker: Yes / No
b) ]f yes, st‹ te country cf origin (tndia/Name of other couritry)
18
c) Passport ^Jo ”"
o) Validity o’ pas"sport ((DD/MM/Y Y) to (DD/MM/YYYY)J
”
KYC Details: (atta‹:h self attested copies of following KYCs)
1 a) 8ank Account No. & IFS Code

b) AADHAR Numb‹yr
c) Permanent Acc‹›un£ Number (PAN}, if available
UNDERTAKING
i} Certified thar the particulars are true to the best of my knowlE dge.
I authorize ftPFO t‹› use my Aadhar for verification/authentica\:ion/eKYC purpose for service delivery.
Kinoiy transfer the funds and service details, ›f applicaDle, from the previous PF account as declared above to the present P.F.
account. (The transfer woul‹1 be possible only if the identified KYC detail approved by previous employer has been verified by
present employer us‹ng his Di(lital Si‹jnature Certificate)
In case of changes in above details, the same wit' be intimate'1 to employer at the earliest

Date :
Pace:
Signature of Member
D E CLAR ATION BY PRESCNT EM PLOYE R
A. The m*mbor [Link]./Mrs.
has joined on and has been allotted PF Number

b. In case I ne person wns earlier not a me 1iL›er of EPF Scheme, 19S2 and EPS, 1995 :
• ( Post *allotment of UAN} ?a*• o'iorted for the member is
• Plea se Tick th e Appropriate OpL› on:
die KYC details of the aou‘« memDer in the JAN database F1a\
•e not teen uploaded
r Hax'e been uploaded but i w ‹I»! r›vud
Hax'e been uploaded and afar ‹›v«J •'itñ DSC
L In case the per son was earlier a mem be o! FPF Sc deme, 1. 52 and EPS, t 995:
• The a’mve PF Account n um ber / UAN of be meml›e as mentioned .in,(A) above was Dcen tagged with his/her LIAN/Previous
Member ID as declared by m'°
 PART-B(EPS)
(PARA 18)
I hereby furnish below particulars of the members of my family who would be eligible to receive
widow/children Pension in the event of my death.

[Link]. Name & Address of the Address Date of Birth Relationship with
family member member

1 2 3 4 5

**Certified that I have no family as defined in para 2(vii) of Employees' Pension Scheme,
1995 and should I acquire a family hereafter I shall furnish particulars thereon in the
above form.

I hereby nominate the following person for receiving the monthly widow pension
(admissible under para 16 2(a)(i) & (ii) in the event of my death without leaving any
eligible family member for receiving pension.

Name & Address of the nominee Date of Birth Relationship with the member

Date :

*Strike out whichever is not applicable. Signature or thumb impression of the subscriber

CERTIFICATE BY EMPLOYER
certified that the above declaration and nomination has been signed/thumb impressed before me
by Shri/Smt./Kum employed in my establishment after he/she has read the
entries have been read over to him/her by me and got confirmed by him/her.

It is further certified that following informations are correct in respect of above said member
as per our records.
1. Date of joining EPF, 1952 :
2. Date of joining EPFS, 1971 :
3. Date of joining EPFS, 1995 :

Signature of the Employer or other

aurhorised Officers of the establishment
Place :

Dated :
EMPLOYEE DETAILS
1 Name of Employee
2 Employee Code
 3 Designation
4 Department
5 Work Profile
6 Date of Joining
7 Location
8 Email Id
9 Personal Contact no.
10 Official CUG no.
Emergency contact person name,
11
mobile no. and relationship
First surety's name and contact
12 no. (Other than blood or first
relative)
Second surety's name & contact
13 no. (Can be your family member
or blood relative)
14 Blood Group
15 UAN number (If applicable)
16 ESIC number (If applicable)
Source (Employee referral/ Job
17
portal/Direct etc)
Does the candidate have any
relative working with Midland
18
Microfin Limited. (If yes, please
mention name & employee code)
19 HR SPOC
20 Reporting Manager
 Alternative to Blank Cheque*:
- Cancelled check of the Guarantor OR Passbook
EMPLOYEE copy OR
DOCKET 6 months bank
CHECKLIST
31 statement
[Link] - Video KYC List of Documents Date Remarks
1 HR Checklist
- Guarantor to visit nearest branch for KYC
322 Reference
InterviewCheck with the
Evaluation 1st and 2nd surety member
Sheet*
333 10th Certificate
Application copy*
form for Employment*
344 12th Certificate
Resume* copy*
355 Graduation
Field Visit Certificate copy*
Report (If applicable)
366 Post-Graduation
Aadhar card copy* Certificate copy*
377 Diploma/
PAN card Certificate
copy* copy
388 Blood
VoterGroup Report*
Id copy*
399 Vehicle Registration
Driving and(Mandatory
License copy* Insurance copy*
in case of Front-end employees)
40
10 Vehicle
AadharPollution Paper copy* (Father, Mother, Spouse, Children)
card of dependents*
41
11 Appointment
Passport Letter*
42
12 Trainee
Police Contract cum Offer Letter (if applicable)
verification*
43
13 Applicant Cheque (Cancelled Cheque & Blank Cheque) *
Equifax report*
4414 Evaluation Test Report
CRIF report*
Disclaimer:
15 -
PAN/DL/Voter verification report*
* Star marked documents are mandatory to submit for joining process and as per company norms
16 EPFO verification report*
* *Male staffs (If unmarried documents of Father & Mother/ if married documents of Father, Mother,
17
spouse Experience
& children).Letter cum Relieving Letter of Previous Organisation*
18 Current Company's
* * *Female staffs Appointment
(If unmarried letter/
documents Offer &
of Father letter *
Mother/ if married documents of spouse &
children).
19 Last 3-month salary slip of current organisation*
Mention
20 Pending
Salary Documents:
account -
bank statement (Last 3 month) *
Personal Verification (Family/ Ward Member/ Sarpanch Member/Government
21
Employee/ Guarantor/ Personal Reference) *
22 Employment Verification (HR / Immediate Supervisor) *
Mention
23 Exceptions:
Annexure A: Compensation Acceptance*
24 Offer letter*
Exception recommended by:
25 Resignation Letter*
Exception approved by:
26 Attachment:
Mail ResignationYes
Acceptance
/ No Letter*
27 Applicant Photograph (5 copy) *
Verification Officer Name Signature
28 Dependents Photograph (1 copy) *
Regional HR
Annexure 17*:
HO-HR Recruiter
-Employee Undertaking
-Declaration of family Loan
29
-Group Mediclaim Insurance & Personal Accident Policy
-ESIC Form
-Form 11- EFP
Indemnity cum Surety Bond*:
- Stamp paper of Rs. 100
- Two Witness aadhar card with photo (1)
- 1st surety's salary slip/ bank statement/Format of salary slip, cancelled
30
cheque, aadhar card copy, office Identity card photocopy (other than family
member or blood relatives)
- 2nd surety's aadhar card, cancelled cheque (Mother/ Father/ Spouse/
Legal guardian)

1
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