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Statement of
.................................................................................
S/o., D/o.
................................................................................... .
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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:-
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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
.....................................................................................
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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.
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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.
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| 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.
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My educational qualifications are as
follows:-
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| 1.
................................................................................................................................................................ |
2
..................................................................................................................................................................
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I can read and write fluently in
.............................................................................................................................................
languages.
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I have / have not been involved in any Civil /
Criminal case and punished by the Court before.
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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.
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I am already in touch with ........... Nos. of
different kinds of independent Social Organisations whose members will invest in Small
Savings regularly.
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I have read the above statement
and found correct.
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Signature of applicant
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/Recorded by me/
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Signature of FO/DSO |