ORDER FORM

Booking period: 01.02.2015 to 31.03.2015

DATE:
To
The General Manager,
INDIA GOVERNMENT MINT,
IDA Phase II, Cherlapally,
HYDERABAD – 500 051.

Please book my order for Commemorative Coins as per the following information:
NAME / THEME OF THE Denomination of Coin Coins Total cost of
S.No. SINGLE COIN(UNC) (Amount specified for each coin) Required ordered Coins
Rs. 10/- Rs. 5/-
1. 60 Years of PARLIAMENT of INDIA 360/- -------
2. 60 Years of PARLIAMENT of INDIA ------ 312/-
3. Birth Centenary of ACHARYA TULSI ------ 312/-
4. 125th Birth Anniversary of ------ 312/-
Maulana Abul Kalam Azad
TOTAL AMOUNT:
NAME / THEME OF THE Denomination of Coin Coins Total cost of
S.No. DOUBLE COIN(UNC) (Amount specified for each coin) Required ordered
Coins
1. 150th Birth Anniversary of
Sri. RABINDRA NATH (Rs.150-QA & 5/-(Ni.Br) Rs.3961/-
TAGORE
2. Birth Centenary of
MOTHER TERESA (Rs.100-QA & 5/-(Ni.Br) Rs.3961/-
TOTAL AMOUNT:

APPLICANT DETAILS:
Name: Address Line 1:
(CAPITAL LETTER):
Address Line 2: City:
State: Pin Code:
Phone / Mobile Email id:
DD No / Date Bank Name and
Branch
Mode of payment
(Tick as applicable) CASH / DD/ BANKER’S CHEQUE Amount in Rs.
Amount in Words : Rupees.

TERMS AND CONDITIONS:

1. The above cost is inclusive of Excise duty, VAT and Postal &Packing Charges for within India.
2. Delivery of Coin Sets: Within 6 months from the date of closure or booking
3. The dispatch shall be arranged through insured speed post.
4. All Transactions are subject to “Hyderabad Jurisdiction only”.
5. D.D. in favour of India Government Mint, Hyderabad, (A unit of SPMCIL) payable at Hyderabad.

Signature of Applicant.
Note: This order form duly filled in signed has to be sent along with Demand Draft to India Government
Mint, IDA Phase II, Cherlapally, Hyderabad – 500 051 and not to any other address.