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