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.
Sl. 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