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
