APPLICATION FOR AGENCY (Important Note: It is essential that every question in the application form is fully and properly answered. Insufficient or in correct answers may result in delay in disposal of application) To, The Regional Director, National Savings for and on behalf of the President of India. Dear Sir, I hereby apply for the agency to canvass for an introduce to Government accounts under the Public Provident Fund Scheme, 1968. I give hereunder; particulars regarding myself which are true to the best of may knowledge and belief. I have read the terms and conditions of agency for canvassing Public Provident Fund and agree to abide by the same and such other conditions as may be imposed by you in this connection. Date: _____________ Yours Faithfully, Place: _____________ Signature: ____________ District : ______________ State: ________________ 1. Name (In block letters) (i) In full Shri/Smt/Kumari ________________________________ (ii) Assigned ________________________________ 2. Nationality ________________________________ 3. Address (In block letters) (i) Residential ________________________________ (ii) Office ________________________________ (iii) Permanent Address ________________________________ (Tick the address on which the appointing Authority should correspond) Note: Please state whether you are an employee or a near relative of an employee of the National Saving Organisation of the Government of India, if you are, you will not be given agency under the Scheme. 4. Date of Birth ________________________________ 5. Educational Qualification ________________________________ 6. a) Present occupation ________________________________ b) If an employment, full name and address of employer and nature of employment ________________________________ c) If in business, details thereof ________________________________ d) Approximate monthly income ________________________________ e) Have you ever been adjudicated insolvent or applied for insolvency or compounded with creditors? Give full particulars. ________________________________ 7. Experience in canvassing work, Business, or personnel connection Or any other special factors which You count upon for success in agency Work of the P.P.F. ________________________________ 8. Full particulars of Father/Husband (If alive) ________________________________ Name ________________________________ Occupation ________________________________ Office Address ________________________________ 9. If already an agent of the Small Saving Scheme give details: - Certificate of Authority Number Particulars of Appointment Area for which the C.A is Valid P.O. to which attached for drawing Commission Address of the District Saving Officer at your permanent place of residence Collections Secured Agency in Savings Certificates in each of the last 3 years 1 2 3 4 5 6 Designation of the Appointing Authority __________________________ Date __________________________ Month __________________________ Year __________________________ 10. Please give names and full addresses of two persons to whom references regarding your character can be made, if necessary. Choose from the following groups only; not more than one from each group - (i) Judge, Magistrate of Honorary Magistrate. (ii) A Gazetted Officer (iii) An Officer of Reserve Bank of India or an Affiliated any Institution. (iv) An Officer of a Scheduled Bank. (v) Principal of a Secondary School or a College affiliated to University. (vi) A Chartered Accountant. Note- Reference should be strictly from the foregoing groups, failing which application will not be considered. The references are not necessary if you are currently functioning as an Authorised Agent of the Small Saving Scheme. Name Designation Address 1. ____________________________________________________________________ 2. ____________________________________________________________________ 3. ____________________________________________________________________ (Signature of the Applicant)
