ANNEXURE V(a)
APPLICATION FORM FOR APPOINTMENT OF COLLECTION AGENCY

1.
Name of the Agency
:
_______________________________________
Proprietorship/ Partnership/Society/Company etc.
2.
Address (including telephone nos.; fax nos. and e-mail address)
:
3.
Established since
PAN Number Present Bankers :
Whether Registered under Shops & Establishment Act or any other Act :
:
Name
Age
Qualification
Experience, if any
4.
a.
Name of Proprietor
Director/(s)
:
b.
Name of Partners
:
c.
Name of Office Bearers
:
d.
Name of key functionaries
:
(Rs. in lacs)
5. Financial Indicators
Previous year
(Audited)
Last year
(Audited)
This year
(Projections)
a.
Equity capital
b.
Tangible Net Worth
c.
Net Profit
6. Infrastructure available
a. No. of people employed :
b. No. of people engaged in Recovery Activity :
c. Out of (b) above, no. of employees:
(i) In respect of which Police verification
has been carried out
:
(ii) Who have been Certificated from IIBF :
(iii) Who have necessary equipments for
audio / video recording
:
(iv) Who have been employed on contract
basis ( also advise average rate of
commission)
:
(v) Who have been employed on
emoluments basis (average salary)
:
d. No. of locations and their addresses along
with phone nos. fax nos. e-mail ids etc.
7. Existing Clientele:
Name of the
client
1st
Assignment
obtained on
No. of assignments
entrusted
No. of assignments
completed
No. Amt. No. Amt.
8. References:
(i) _________________________________
(ii) _________________________________
9. Information furnished above is correct to the best of my knowledge & belief. Copy of
the documentary proofs, wherever applicable, duly certified by me are enclosed
(Name & Signature)
Designation:
Date:
Particulars verified and comments, if any:
(Authorised Bank Official)