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FORM A

FORM OF APPLICATION FOR PURCHASE OF KISAN VIKAS PATRA

Serial No. ..............................

To

The Postmaster      ..........................................................................................   Post  Office     


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.)

 

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
1.  

 
2.  

 
3.  

 

 

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

4. The Certificate(s) and Identity slip may be made over to my/our agent Authority No……………........ or messenger who presents this application.



Signature (s)thumb impression of Investor(s)
 

Signature and Address of witness to nomination

 

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 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

------------------------------------------------------------------------------------------------------------------------------------------------

Identity slip



Specimen signature of holder/holders