1. Name of the bank

2. Name of the institution & its full postal address where Extension Counter is sought to be opened.

3. Name & address of the base office of the bank to which E.C. is proposed to be attached.

4. i ) Distance between the base office and the proposed extension counter.

ii) Distance between the proposed E.C. and the nearest office of the applicant bank (including E.C., mobile office, satellite office etc.)

iii) Distance between the proposed Name of Type Distance E.C. and the nearest offices / bank of extension counters, mobile office offices etc. of *Other banks

(including urban-Co.op. banks) _______ _______ ______

(i) * Other than the bank
(ii) applying for the
(iii) counter
(iv) Particulars of Employees' Co-op. Credit Society, if any, functioning in the premises.

5. i ) Name of the Principal Banker to the institution at which the Extension Counter is sought to be established.
ii) Whether the institution has agreed to provide accommodation for housing the E.C?
iii) Whether the institution has any objection to the members of the public other than the staff / employees / workers / institution being allowed access for availing of banking facilities within the campus /premises at the extension counter? If so, the reasons therefor.

(A LETTER FROM THE COMPETENT AUTHORITY OF THE INSTITUTION AS IN THE PRESCRIBED PROFORMA GIVEN IN PART II OF THE APPLICATION SHOULD BE ENCLOSED IN SUPPORT OF THE ABOVE)

6. i) Name/s of the banker/s other than the Principal Banker to the Institution referred to in 5 (i)
ii) The type of accounts & extent of deposits maintained by the institution with each of the above banker/s.

7. i) Number & types of clientele specifically attached to the institution whose banking needs are to be catered to
(Please give separate figures)

Staff/Workers/Students/Teachers/Others* (specify) TOTAL :________________

ii) Estimated No. of other general public etc. whose requirements are to be met :________________

8. (a) Amount of deposits expected within two years of operation at the counter from :
First Year    Second year
No. of Amt.  No. of Amt.
A/cs.           A/cs.

(b) Daily quantum of cash transactions                                       Number Amount Number Amount
* Delete whichever is not applicable

9. Reasons for opening an E.C.

10. Nature of transactions to be conducted at the proposed E.C.

11. Amount of rent, if any, payable (excluding incidentals)
by the bank, rate of rent & areas offered
for locating the extension counter.

12. Amount of commercial rate of rent
as prevalent in the area or as approved
by State/Central Govt.

13. Brief calculations as to the viability/
economics of the proposal for a period
of 3 years.

Date:________________
(Signature & Seal of the applicant bank)

PART - II
Date:__________

1. We have requested____________________________ to open its extension counter in the
(Name of the bank)
premises of_____________________________________________ for the benefit of the
(Name & full address of the institution)
following persons attached to the above institution. @

* Workers ………….. Please indicate

* Staff/Employees ………….. actual numbers

* Students ………….. separately

* Teachers …………..

@ (Where there are more than one institution being managed by the authority issuing this letter which are also to be benefitted by the E.C., the names of these institutions, their distance from the proposed location of the extension counter, the number of students/staff etc. attached separately to each of the institutions, the name and the distance of their bankers should also be indicated separately).

* (Strike out whichever is not appilcable)

2. (a)______________________________________________________ is our
(Name of the bank and place)

3. We undertake to provide necessary accommodation for the extension counter within the premises of our institution (mentioned at S. No. 1 above).

4. We have no objection to allow outsiders to have access to the extension counter.

5. If the extension counter is proposed to be allowed to a bank other than the principal banker, the reasons therefor.

6. Whether a similar letter to any other banker for the purpose has been issued :

(Signature of Competent Authority on behalf of the institution mentioning designation and seal, if any)