| Emp. Code No. : | ||||
| A/C No. : | ||||
| Name of Applicant : | ||||
| Father's / Husband's Name : | ||||
| Mobile No. : | ||||
| Section and office where working : | ||||
| Office Telephone No. : | ||||
| Designation : | ||||
| Basic Pay : | ||||
| Date of Superannuation : | ||||
| Date of Birth : | ||||
| Permanent Address : | ||||
| Amount of loan applied for : | ||||
| Nature of loan i.e., Ordinary or Emergent : | ||||
| Number of instalments by which it is proposed to repay the loan (Not more than 30) : | ||||
| Purpose for loan is required : | ||||
| Indebtedness to any other co-operative Society : | ||||
| Any other outside liabilities : | ||||
| Name of Sureties : | Name | Office Address | Designation | A/C No. |
| 1 : | ||||
| 2 : | ||||
| 3 : | ||||
| Outstanding liability of the application to the society : | As principal borrower | Person of Persons | ||
| As surety to | Amount Due | |||