Form No..................
Ph.: 011-41070029 Mob. : 9999536638-39 E-mail : [Link]@[Link]
Regn. No. 2807
Date of Birth Age : Male Female
Name of Spouse (If Married)
Mobile No. Phone No.:
Permanent Native
Mobile No. Phone No.
Designation/Salary (per month)
(including all allowances) Designation.........................Salary (Gross)..............................
Are you an existing subscriber
Yes / No.
with Southern Star Chits Pvt. Ltd.
Mem No.
1
Sir,
I/We request you to register my/our name to be considered for allotment of a chit ticket as per
details given below:
Chit Group Chit Value Monthly Period (Months) Ticket No. Receipt No. & Date
Subscription
I/We have remitted this day by Cash/Cheque a sum of Rs. ...............................being the first instalment
to..............................Chits in Group .......................above mentioned. I/We request you to register and
take me/us a subscriber as per the terms and conditions of your chit fund rules and regulations which
I/We here by agree to accept. I/We have completely read or caused to be read, translated and completely
understood the said rules. I/We do hereby agree to abide and be bound by your current rules as well as
any future amendments that may be made thereto. I am not a non-resident of India.
Place :
Date :
Your’s faithfully
Name & Signature of Applicant
(Name & Signature of Executive)
Amount Received Rs. ............................................ By cheque/Draft/M.O./Cash/NEFT on..........................
Authorised Signatory