NC - 69(A)
Form “A” (WHITE)
See Rule 7(1)
FORM OF APPLICATION FOR PURCHASE OF KISAN VIKAS – PATRA
(BY DIRECT INVESTMENT)

To Serial No……………………
The Postmaster
……………………….
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’/Jont “B” a In the name(s) of ………………………. and ………………………………..
b In the case of minor, his date of birth ……………………….. encashable by the
minor’s parent/guardian Sri/Smt ………………………..
c The investment is not through any agent
2 I/We nominate the person(s) named below who shall on my/our death, receive
payment
Sl No
Name of 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 certificates/identity slip may be handed over to my/our messenger who
presents this application.
Signature and Address Signature/Thumb impression of investor
Of witness to nomination
Date …………………………………….
Address …………………………………
…………………………………………..
Received the certificate(s) and identity slip
……………………………………….. Signature of investor/messenger
Delete whichever is not applicable Date ……………………………………..
Identity Slip
Specimen Signature of Holder/Holders
TO BE COMPLETED BY THE POST OFFICE
Sl No of
Certificate
Issue Price
Rs.
Date of
encashment
Initials of the
Postmaster
Remarks like
transfer, issue of
duplicate etc with
initials
Total
Date Signature of Postmaster