Bethany Complex, Thrissur Road, Kunnamkulam. Ph : 04885-228566
APPLICATION FORM
Name Of Applicant
Postal Address
Pin Code
Name Of the Nominee
Relationship
Father / Mother / Husband's Name
Details for Documentation
Taluk
Village
Desam
Occupation
Age
Tel. No.
Mobile
E-mail
Full adress of the Nominee
Dear Sirs,
Having completely read or caused to be read and fully understood the rules governing the conduct to the chit which is proposed to be started from
day of
and assented to the same, I,hereby remit a sum of Rs.
(Rupees
only ) by cash
/ DD
/ Cheque
No.
. dated
Draw on
being the first instalment of
Numbers ticket of chit No
Pooval
/Quarterly
/Bi-Mly
/Monthly
. I request you to allot me the ticket and I, also hereby agree to any change in the commencement of the chit.
Witness
Signature
Yours faithfully,
Sd/-
Signature of Subscriber
Ticket No.
stt No.
Cust Code
Entd. By
Cashier
Act/ Manager
Place
Date