Directorate of Small Savings & Lotteries, Goa
DECLARATION
(To be furnished by the PPF Agent along with the application)
I_______________________________W/o, D/o. S/o Shri.___________________ Solemnly affirm that:-
1. I am not employee of the State or Central Govt. and undertaken to report to the appointing authority and to give up the agency whenever I enter such employment.
2. None of my near relatives is employed in the National Savings Organisation any where in India.
3. None of my near relatives is employed in the Postal wing anywhere in India in Gazetted capacity and in non-Gazetted capacity any where in the State where the Agency falls.
4. I declare that none of my near relatives is employed under the State or Central Government.
OR
I give below the particular of near relative who is an employee under the Central/State Govt.
Name of the close relative
Relationship
Particulars of office where employed
I attached no Objection Certificate (s) from the head (s) of Office/Department where the above mention person is/are employed to the effect that there is No Objection to my taking up agency under the above said agency system.
A person will be regarded as near relative if the official is the person wife/husband/legitimate child/step child/ brother/step brother/sister/step sister/sister in law/brother in law/son in law/daughter in law/father in law/mother in law.
Date:
Place:
DEPONENT
Signed in my presence:
(1) Name and Address Signature (2) Name and Address Signature

CONDUCT CERTIFICATE
Certified that he/she ______________________________________
S/o,W/o,D/o.__________________________________________________
R/O. _________________________________________________________
Is personally known to me for the last _________ year ( Not less than 2 years )
and to the best of my knowledge and belief he/she is a person of integrity and good conduct. He/she is not related to me.
Date: Signature:
Name and address:
Seal:
CONDUCT CERTIFICATE
Certified that he/she ______________________________________
S/o,W/o,D/o.__________________________________________________
R/O. _________________________________________________________
Is personally known to me for the last _________ year ( Not less than 2 years )
and to the best of my knowledge and belief he/she is a person of integrity and good conduct. He/she is not related to me.
Date: Signature:
Name and address:
Seal: