Form A1 (Coloured)
[See rule 7(1)]
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.

SI. 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 made over to my/our agent Authority No. or messenger who presents this application.
                                                                   Signature/thumb impression
                                                                    Date
Signature and address of                            Address
witness to nomination                                
                                                                     Received the certificate(s) and identity slip
                                                          Signature of investor/messenger/authorised agent
                                                                    Date
 Delete whichever is not applicable.
Identity slip
 Specimen signature of holder/holders

To be completed by the Post Office

Serial Nos. 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