1. Qubyk Services Pvt. Ltd. APPLICATION FORM FOR ENTREPRENURE Qubyk Services Pvt Ltd 1.Location(Village/Town)Location____________________________Distric____________________________________________ State_________________________Pin____________________________________________ 2.Name (IN BLOCK LETTERR)_______________________________________________________________________________ 3.Father’s/Husband Name ______________________________________________________________________________ 4. Date of Birth(Age) ______________________________________________________________________________ 5. Gender (Please Tick) - Male ___________ Female ___________________________________________________ 6. Marital Status (Please Tick) - Married ____________________________Unmarried ___________________________________ 7. Education (Please Tick) - Class X ______ Class XII ______ Graduate ____ Post Graduate and above 8. Permanent Address Mohalla / Village______________________________________________________________ Post___________________________________Tehsil________________________________ Distric__________________________________State_________________________________ Pin Code_____________________________________________________________________ 9.Communication Address Mohalla / Village______________________________________________________________ Post___________________________________Tehsil________________________________ Distric__________________________________State_________________________________ Pin Code_____________________________________________________________________ 10.Telephone(With STD Code) Residence_________________________________Office_______________________________ Mobile Number_________________________________________________________________ 11. Email ID(With any) ____________________________________________________________________________ 12.Curently Bank (With Bank) _____________________________________________________________________________ 13. Bank Account Number(If any) _____________________________________________________________________________ 14. Cheque Facility (Please Tick) _____________________________________________________________________________

2. Qubyk Services Pvt Ltd 15. Present Bussiness / Occuption, If any _________________________________________________________________________________ 16. Computer Literacy _______________________________yes _______________________No______________________ 17. If Yes Nature of Qualification __________________________________________________________________________________ 18. If You Already Own A Bussiness or Are Working Your Revenue / income Per Month Including Pension if Any is less Than Rs.5000- Rs,1000 Rs.10000---------------Rs-20000 Rs----20000 ---Rs-30000 More Than Rs -30000 (Please Inclose Copy of I.T. Return / pensio Payment certificates) Do You have Any experience in selling Financial products ? If yes, Give Details 19. Language known (say fluent / not so fluent) Read write Speak 20. No. of years of stay in the town / village In town In Village 21. Do you have any police records? If yes, give details. _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ 22. Name, address and occupation: ___________________________________________________________________________________________ Of two people to whom reference can be made________________________________________________________________________________ 23. Political Affiliation, if any: - ________________________________________________________________________________________________ 24. Default if any to Banks / Financial Institutions: - ________________________________________________________________________________ 25. Infrastructure available: (Office, area, location, computer, Internet, Tel No, etc) :- _____________________________________________________ _____________________________________________________________________________________________________________________ 26. Name of the office from which retired. :-______________________________________________________________________________________ 27. Position at the time of retirement ___________________________________________________________________________________________ (Plz. give brief of various positions held and role)

3. ; Qubyk Services Pvt Ltd 28. Any disciplinary action taken against you while in service (if Yes, please give details. Please enclose a certificate of Conduct from your last the employer) 29. Particulars of liabilities: -___________________________________________________________________________________________________________________ 30. Particulars of movable property and Investment. :- ______________________________________________________________________________________________ 32. Particulars of Immovable property. :- Land___________________, Village ________________________ Survey/PattaNo. _________________, Area _________________ 33. Are you willing to invest in the POS/Kiosk machine and other equipment required for carrying out transactions as CSP / KO of Business Correspondents? What is the cash balance you are ready to invest for making cash payments / receipt of deposits as Business Correspondent? Date :- ______________ Place :- ______________ Signature of the Applicant

4. Qubyk Services Pvt Ltd SCORING SHEET FOR CUSTOMER SERVICES POINT / SUB-AGENTS/FRANCHISEE Name of the Applicant: - _________________________________________________________________________________________________________________ Category of Applicant: - __________________________________________________________________________________________________________________ Part - A - Quantitative Assessment SR NoParameter Criteria MarksMax MarksMarks scored 1 Office A i) Non-residential ii) Residental iii) Located elsewhere at the centre i) Satisfactory conduct certificate submitted ii) ii) Not submitted 522522 5252 2 Employer’s ** certificate submitted (if employed in past) Opinion Report of Present Banker bank 5151 2 3 i) Submitted / Acceptable ii) Not submitted / Not-acceptable 1010 1 References of two persons known to bank 4 i) Submitted / Acceptable ii) Not submitted / Not-acceptable 1010 1 5 Distance-area of operation i) Distance between the place of business of VLE& link branch in within 15 Kms. ii) Beyond 15 Kms to 30 Kms 2121 2