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Statement of .................................................................................
S/o., D/o. ................................................................................... .

I have applied for the appointment of Authorised Agent under Standardised Agency System, I ................................................. S/o., D/o. ............................................................. aged   ....................years residing at ........................................................ ........................................................................... for the past ............ years declare as follows:-

I am doing/not doing business at present in ........................ .................................. and the place of business is ...................... ............................................ My present / past occupation is / was   ....................................................... and the address of the employer is /was .......................................................................................................................................................... and retired from service on .....................................................................................

I am/ not a close relative of a Gazetted/non Gazetted Officer working in the Post & Telegraphs  Department, National Savings Organisation, Central, State or Union Territory Government.

I give below the names of my near relatives duly indicating their present official designation and address who are employed under Post & Telegraphs Department, Central or State or Union Territory Government.

Name and Address Designation and office address
1.....................................................
.......................................................
.......................................................
.....................................................
.......................................................
.......................................................
2......................................................
.......................................................
.......................................................
.....................................................
.......................................................
.......................................................


I do/ do not submit herewith the no objection certificate in original to the effect to myself being appointed as agent under Standardised Agency System in original issued by the Head of Office / Department of my above relatives.

My educational qualifications  are as follows:-

1. ................................................................................................................................................................
2 ..................................................................................................................................................................

I can read and write fluently in .............................................................................................................................................    languages.

I have / have not been involved in any Civil / Criminal case and punished by the Court before.

I am already in touch with .............. Nos. of Income-tax Assessees .............................................. Nos. of big /small businessmen,   ................................. Nos. of Theatre/ Studio Owners ,  .................. Nos. of Doctors/ Lawyers and Engineers .................... Nos. of leading / ordinary Actors / Actresses/ Producers/ Directors and other leading Artists in the Cine field, ............. Nos. of big Hotel / Lodges Owners ................ Nos. of other leading Industrialists................. Nos. of State / Central Union Territory Government Servants and .....................  Nos. of highly designated officers in well established private concerns and State/Central Government undertakings who will invest a sizeable amount every year in Small  Savings.

I am already in touch with ........... Nos. of different kinds of independent Social Organisations whose members will invest in Small Savings regularly.

I have read the above statement and found correct.

 

Signature of applicant

/Recorded by me/

 

Signature of FO/DSO