APPLICATION FORM FOR AN INDIVISUAL FOR APPOINTMENT AS AUTHORISED AGENT

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To

The (Appointing Authority)

Sub :Application for appointment as Authorised Agent. 

Sir;

I request that I may be appointed as an authorized agent under the Mahila Pradhan Khetriya Bachat Yojana for canvassing and securing deposits in 10 and 15 years post office cumulative time deposit/five year Recurring Deposit Accounts on a commission (at such rate as may be notified by the Government of India from time to time) in the………………….area (Municipal) House no/Plot no… ……… to …….. which consists of……………. Families.)

2.     I agree to abide by the rules and regulation regarding the appointment of authorized agents at Present in force and as may be amended from time to time under the above said agency scheme.

2(a) I am not employed under the Central/ State Government

2(b) I declare that none of my near relatives (i.e. my husband, legitimated child, step child,

my husband's father, mother, sister or brother etc. as defined above) is employed under

Central/ State Government

                                                   OR

I give below the particulars of my near relations (my husband, legitimate child or step child, my or my husband's father, mother, sister or brother) etc. as defined above who are employed under the Central/ State Government

I attached "No objection certificate(s) from head (s) of office/Department where the above mentioned persons is/are employed to the effect that there is no objection to my taking up agency under the above said agency scheme.

   3.     I shall provide a security of Rs.500.00 (Rupees five hundred) only in shape of 6-year

National Savings Certificate duly pledged to President of India.

                                                OR

I shall furnish two personal sureties of Rs.5000.00 each as prescribed in para-5 of Executive instructions .

                                                 OR

I shall furnish a fidelity Guarantee Policy of Rs.500.00 in the manner prescribed in para-5 of Executive instructions .

  4.   The Agreement (FORM ASLAPS-3) will be executed by the me immediately on hearing from you about the approval of my appointment as on Authorised Agent.

I enclose herewith my five-specimen signature.                                  

                                                                                   Yours faithfully,

                                                                 (Name & full address of the Applicant.)

FOR USE BY THE DISTRICT SAVINGS OFFICER NATIONAL SAVINGS/DISTRICT SMALL SAVINGS OFFICER (D.S.S.O.), GOVERNMENT OF ORISSA

Memo No………………                                                                            Dated……………….

                           Forwarded to……………………………………………………………………………

                                            (Appointing Authority)

..........................................................................................................................

Recommended that the applicant may be/may not be appointed as authorized agent on account of the following reasons.

                                                        Signature …………………………………………….

                                                                    (District Savings Officer)

                                                                  National Savings/D.S.S.O.              

         Government of Orissa.

                                                                        Place……………..

FOR THE USE OF APPOINTING AUTHORITY

Appointment as recommended by the District Savings Officer, National Savings/District Small Savings Officer approved/ not approved.

    (Designation of the Appointing Authority)

Place :-

Date :-

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