UNION HEALTH APPLICATION FORM
PERSONAL AND EMPLOYMENT DETAILS
Name
Surname First Name Middle Name
Current Residential
Address
Phone No. E-mail (if any) -
Date of Birth (ddmmyy) ____________ Age: Yrs ı Male ı Female
Marital Status ı Single ı Married
Number of dependants Children - Others -
Status ı Resident ı Non-Resident
Qualification MBBS / MD / Other (please specify)
Occupation ı Employed ı Self-Employed
EMPLOYMENT RECORD – FOR SALARIED / SELF EMPLOYED
Name of the Employer
Company / Firm Address
(Please mention the
address of the office you
are based at)
Designation Department / Section :
No. of year in Current
Employment business
Years :
Employee No. Income Tax Permanent a/c no.(PAN) :
Office phone No. Ext. (if any) : Fax:
Monthly Income Rs Date of Salary Receipt:
Other Income Rs
No. of yrs in present occ. Yrs Retirement Age: Yrs
FINANCIAL INFORMATION
Savings, Investments Etc.
Particulars Applicant Co-applicant
(Rs) (Rs)
Savings in Bank __________ ____________
Immovable property
(specify) ___________________________________
__________________________________________
Current balance in
Provident Fund (your share) _________________
Other Assets (specify)
1. ____________ ___________
2. ____________ ___________
LIC Policy(ies) ____________ ___________
Postal Life Insurance
Policy(ies) Amount ____________ ___________
Maturity Dates ____________ ___________
Loans Taken / Proposed
Please indicate below all loans taken / proposed from
employer, Provident Fund etc., and installment(s)
payable per month including interest against each loan.
(Rs) (Rs) (months)
Source Outstanding Monthly Term
Of Loan Amount Installment
Payable
Applicant:
Employer
Provident Fund _________ _________ __________
Credit Society _________ _________ __________
Others (specify) _________ _________ __________
Co-applicant
Employer
Provident Fund _________ _________ __________
Credit Society _________ _________ __________
Others (specify) _________ _________ __________
AFFIX RECENT
PHOTOGRAPH OF
APPLICANT
WITH
SIGNATURE
1. Please write or type in Block Letters.
2. Put a tick mark against appropriate item.
3. Ensure that all information is correctly filled in. If any detail is not applicable,
please write “N.A”.
4. Enclose all required supporting documents and project report.
Purpose of Loan: Loan Amt.:
BANK ACCOUNT DETAILS
Name of the Account Holder Name of the Bank & branch Year a/c opened Account No.
GENERAL [APPLICABLE TO APPLICANT AND CO-APPLICANT (IF ANY)]
Yes No
1. Have you or your spouse earlier
applied to UBI for a loan ? ı ı
If yes a) Loan a/c no. _______
b) Other details ____________
2. Have you or your spouse given
Personal Guarantee(s) ? ı ı
If yes, a) On behalf of ___________________
b) Name of the organisation______________
c) Amount ______________
3. What other security will you be able to provide
_____________________________________
4. Please select the mode of repayment convenient
to you: Tick (
) against the appropriate box.
a) Deduction of monthly installment
By your employer ı
b) Post dated cheques ı
c) Standing instructions to bankers ı
d) Any other (please specify) ____________
Not applicable for employed applicants, whose
employers have a deduction at source arrangement
with UBI?
Are you a citizen(s) of
India?
ı Yes ı No
Do you belong to
ı SC ı ST ı NA
Do you have any Credit
Cards? Yes / No
If Yes, Card No.:
Issuers name:
REFERENCES (NAMES AND ADDRESSES OF TWO REFEREES WHO ARE NOT RELATED TO YOU)
UBI may make such
enquiries from the
referees if it deems
necessary.
1. 2.
Phone
Off: Off:
Res: Res:
DECLARATION
I / We declare that all the particulars and information given in the application form are true, correct and they shall form the basis of any loan UBI may decide to grant me / us. I / We confirm that I / We have had no insolvency proceedings against me / us nor have I / We ever been adjudicated insolvent and further confirm that I / We have read the brochure and understood the contents. I / We am / are aware that the Equated Monthly Installment comprising principal and interest is calculated on the basis of quarterly rests. I / We agree that UBI may take up such references and make such enquiries in respect of this application, as it may deem necessary. I / We undertake to inform UBI regarding any change in my / our occupation / employment and to provide any further information that you may require. I / We also undertake to authorise my / our employer(s) to deduct Equated Monthly Installments from my / our salary and remit the same to UBI directly every month. UBI may make available any information contained in this form, other documents submitted to UBI and information pertaining to the loan to any institution or body. UBI may seek / receive information from any source / person to consider this application. I / We further agree that my / our loan shall be governed by rules of UBI which may be in force from time to time.
Applicant’s Signature
FOR OFFICE USE ONLY
All the documents obtained as per scheme, verified with original (wherever applicable) and found to be in order
(Signature & name of processing officer)
SANCTIONED / DECLINED
(Signature & name of sanctioning authority)