Directorate of Small Savings & Lotteries, Goa
APPLICATION FOR RENEWAL OF MPKBY AGENCY
From:
Name :___________________
Address: _________________
__________________________
Phone No. ________________
Dated: ___________________
To
The Director,
Directorate of Small Savings & Lotteries,
Serra, Bldg. Nr. All India Radio,
Altinho, Panaji, Goa. 403001
Sub:- Renewal of MPKBY Agency No. NSO/DSSL/MPK/________
Sir,
I hereby request you to renew my Agency MPKBY Agency which is expiring on 31st March 2009.
I am enclosing herewith original Certificate of Authority and last renewal order for necessary endorsement.
I declare that I am not employed under the central or State/Union Territory Government.
I declare that none of my relatives ( i.e. Husband, Legitimate Child, Step Child, My Father, Step Father, Mother/Step Mother, Brother/Step Brother, Sister/step Sister, Father in Law, Mother In Law, Brother in Law, Daughter in Law ) is employed under the Central or State/Union Territory Government.
My Per Month Collection is _______________
My Per Month Account is _________________
Thanking you in anticipation.
Yours faithfully,
Encl: As Above.