Form "A"


FORM OF APPLICATION FOR PURCHASE OF KISAN VIKAS PATRA
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Serial No.........................................

To
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The Postmaster ......................................................................................Post Office
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........................................................................ .........................................................   ko naama (naamaaoM) maoM
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1. I/We hereby tender Rs. ..............................(Rupees .............................................................................Only) in cash/by cheque No. .................... for the purchase of Kisan Vikas Patra of the type Single/Joint "A" / Joint "B"
(a) In the name(s) of .................................................................. and ..................................................................
(b) In case of minor, his date of birth ..................................................... encashable by the minor's parents/guardian Shri/Smt................................................................................................
(c) In the name of ............................................. (Members etc.) through .......................(Society or Company etc.).
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2. I/We nominate the person(s) named below who shall on my death, receive payment:

Sl. No.

Name of Nominee


Full Address

Date of Birth of minor Nominee

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2.      
3.      

3. I / We hereby agree to abide by the Kisan Vikas Patra Rules, 1988.

The certificate(s) and identity slip may be made over to my/our agent Authorised No........................ or messenger who present this application.

Signature and Address of witness to nomination               Signature(s) / Thumb impression of investor(s)

 ........................................................             Date .........................................................

........................................................              Address...................................................... 

                                                                          Received the certificate(s) and identity slip

 

                                                                Signature of investor/messenger authorised agent

                                                                Date ..........................

.................................

Delete whichever is not applicable

To be completed by the Post Office

 
Serial No. of Certificate Issue price Rs. Date of encashment Initials of the Postmaster Remittance, transfer, issue of duplicate etc. with initials
         
 Total        

Date......................                                                                Signature of the Postmaster

 

Identity Slip

                                                                                Speciman signature of holder/holders