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- Chit Fund Application Form
- Declaration and Agreement
A. Agile end es gous somn giles eareias
ZA Chit Fund Agile Chit Fund Company Pvt. Ltd.,
Accountability. Transparency Trust
2nd Floor, Basaveshwara Poly Clinic, I.G. Road, Chikmagalur. Pin - 577101.
Ph: 08262-230135 | e-mail: info@[Link] | [Link]
Branch / weet
A SL LOL ceden ane Ni
Foreman’s Commission
Chit No. Instalment chit Amount Rs. Rs,
" Amount Rs. " nn see smeee
wets toad, | ose ce ae, | Bt Reg de. | Seas ema Penge
oe. -acress the photo
Full Name (Mr/Mrs/ Ms)
Borsa saw (S¢/ Sens)
2. | Age & Date of Birth Sex: Male (—] Female[—]
uty sy 05 mos ex ross E]
3 | Father's Name
Soros sires
+ | a) Marital Status Waried Unmaried
6) tym eno
b) If married, Spouse's name
18) cenazengd ws /esgyas asc:
5. | Educational Qualification (s)
eoyscdiice
6. | Permanent Address with pin code
Telephone / Mobile No. :
mote Dew entdaentincart
Ginvmnd mod, [dade woe:
6a | Intimation through SMS alerts
eminoam shace ames
Present Residential Address with
Pin code & Telephone No.
wena mea qd Beret
anidaeaidzoad david woe:
8. |a) Occupation 2) evcimers
) Designation =) sciwoss
9. | Business / Office Address along
with Telephone No.
ysis /acleo uae sich
ciaceed dost;
E-mail / ashes
AStng CIN: Us5992KAz014PTCO74245 b) Source of Income:
10 a) Income (Monthly) Rs. Salary [7] Agriculture [7] Business (] Profession
©) emnos (anes) da, 8) aenaie chae:
vO @~O =o
11. | Name & Address of Nominee(s): Age Relationship with Share of Nominee
Roteys Bath soy Ouewnie: Bosay applicant Roings me
surmccaent Zoned
2: | Chits in any held currently Chit No. Subscriber No.
cingde Seonwe avin and ec woe, dommad woe,
+: DECLARATION :-
| do solemniy affirm end state that the particulars furnished above, are true and correct to the best of my knowledge
and belie!
\ have fully read or caused to be read, translated and thoroughly understood the chit and if| am allotted Ticket in the
chit requested for, I do hereby agree to be bound and abide by al the terms and conditions.
Jam remitting Rs. (Rupees only} by cash
/DD/ Cheque deing the first installment towards the above chit Group
types
BOWS, ws ses Aetacd
Name and address of reference:
OuobEY sic shay Ovo:
Phone No.
Ravers xoss;
Phone No...
Dat
Signature ofthe Applicant
feoeS Ale
amos:
For Office Use only: eikOch wwmckaens eg
Chit No.:
Verified & Enrolled by... ‘Subscriber No=
modron, onaddanictee aie Hod,
Momends Hot
Date... Signature of tie Foreman
amor: SDs xb
AStng CIN: Us5992KAz014PTCO74245
