NC-69A1 FORM A1 (COLOURED)
FORM OF APPLICATION FOR PURCHASE OF KISAN VIKAS PATRA
(BY INVESTMENT THROUGH AGENTS)
Serial No……………………
To
The Postmaster…………………………………….. Post office
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)……………………….and ……………………….
b) In the case of minor, his date of birth……………………
encashable by the minor’s parent/guardian Shri/Smt ……….
c) Agent’s name ……………………………..
d) Certificate of Authority No……………………..
2 I/We nominate the persons named below, who shall, on my/our death,
receive payment :
Sl No Name of the nominee Full address Date of birth of
minor nominee
3. I/We hereby agree to abide by the Kisan Vikas Patra Rules,1988.
4. The Certificate/Identity slip may be made over to my/our agent Authority
No……………….. or messenger who presents this application.
Signature/thumb impression of investor
Date :
Address__________________________
________________________________
________________________________
__________________
Signature & address of
Witness to nomination
Received the certificate(s) & identity Slip
________________________________
Signature of Investor/Messenger/
Authorised agent
Delete whichever is not
applicable. Date :___________________________
Identity Slip
Specimen signature of holder/holders
TO BE COMPLETED BY THE POST OFFICE
Sl.No.of
Certificates
Issue price
Rs
Date of
encashment
Initials of the
Postmaster
Remarks like
transfer, issue of
duplicate etc, with
initials
Total
Date : Signature of Postmaster