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APPLICATION FORM (DUPLICATE/APPLICANTS COPY) Date. Details of Applicant (Remitter) Name .. Date of birth Category: SC/ST/PWD - ONLY POSTAGES-RS.75/OBC/GEN - Application fee & postages Rs.350/-. Details of Beneficiary 1. Centre 2. Bank/ Branch 3. Name (Beneficiary) 4. Current A/c No. : : : : :
Date.
Details of Applicant (Remitter) Name .. Date of birth: Category: SC/ST/PWD- ONLY POSTAGES-RS.75/OBC/GEN - Application fee & postages Rs.350/-. Details of Beneficiary 1. Centre 2. Bank/ Branch 3. Name (Beneficiary) 4. Current A/c No.
Mobile No.
Mobile No.
: : : :
MYSORE STATE BANK OF MYSORE, MYSORE MAIN. CAUVERY KALPATHARU GRAMEENA BANK 64078379003
MYSORE STATE BANK OF MYSORE, MYSORE MAIN. CAUVERY KALPATHARU GRAMEENA BANK 64078379003
Amount to be remitted Rs (Rupees.......................) Remit the amount as per details enumerated above. PAYMENT PARTICULARS-CASH
Rs. AMOUNT SERVICE CHARGES TOTAL Ps.
Amount to be remitted Rs(Rupees.......................) Remit the amount as per details enumerated above. PAYMENT PARTICULARS-CASH
Rs. AMOUNT SERVICE CHARGES TOTAL Ps.
Applicants Signature
FOR BANKS USE ONLY
DATE..
(Rupees.)
(Rupees.)
Cash Received
Cash Received