APPLICATION FORM FOR SOVEREIGN GOLD BOND 2016 (Put ¥ wherever required) ‘Wame of Genki Post Oftice ‘Name of Branch Meio of Ssosrtion cash CD creaue, 00, Cl etectone tars aa ' ‘Cheque /Derana Drat Drawn on ‘Choque Derrand Gramsof Geiarpptedter | Name the Bank & anc) Draft No. atau) inward) “Amount: Ra. nfs) (ino) PAN number apples nt(s) Detail (in block letters) FIRST SOLE APPLICANT'S NAME IN FULL status; Resident Incvdual( Tests), Charitable ists), Universi, eters Please speciy EXISTING RB INVESTOR 0, IF ANY ‘ate of Bh (miner ‘easprihrar/PANTTAN tri No any ane ote above) ‘SECOND APPLICANTS NAME IN FULL ‘aaspsikarFAN TANT WoO Wanye ae oe) ‘Gaara in cae oT mP FIRST/ SOLE APPLICANT'S / GUAROIAN'S ADDRESS IN FULL (00 NOT FILLIN NAME AGAIN) CONTACT DETAILS. rene Ena Account Helder Name Bank Name french Name Adress 2m ey ‘BANK PARTICULARS FOR PAYMENT OF INTEREST WARRANT / REDEMPTION ecount No, tse Code I I we] . ecount Type [1] se Account []curent Account esvnge deta: Nomination Far (a8 apse) be fed and atiochedDepository participant details avai otoptontohald he born deat tn) Depastoy Nome CJ soe [J cos. [Picea I (For NSDL, ete 8 dig ID folowed by 8 ciptclentO, For COSL ener 16 gt cent) CTT Declaration: Ie hereby declare and undertake that () my/our aggregate investment in Sovereign Gold bonds does not exceed 500 Grams during the financial year 2015-16 and (i) the Information furnished in this application form is correct, ii) have read and understood the details of information for the investors as well as rights and duties of investors (copy attached), The agentibank has explained the features of the scheme, Sonunre Soraure Sorance serhepcat 2oshepcan umn Date TT Place I EEGie=s= 7 ee Ont, ark Stam & Soa te attend oa othe trot ce ‘Incase of thumb impression, attestation by two witnesses Tb npn Witnesses: = Name stones, Ne fn ets, Sona Serave, HUF, declaration (mandate, applicants Kara of HUF) ind Unanviced Family and as such have ul powers to sl endorse, vanser or oherwise oe ofthe HUF ‘Specimen signatce fr anon behalf of he HUF (name ofthe Pace: HUF) For Office use only residing ane adress gven again! Fest Appian, do Slerny ati that am te Kata of he inthe Sovereign God bonds 2016, standing nthe name (Signatr ofthe Kara with sal of HUF) tT] q Sm a eet | BANE] GFT [ner caE| Nain] z =] wa ‘of Application | Govt. AIC registered on | tion obtained | declaration cae inform eae kien | SBnir | Sm | “ane” | Se | " 3eu