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:
[email protected] | www.agilechitfund.com
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[—]
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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
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Present Residential Address with
Pin code & Telephone No.
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anidaeaidzoad david woe:
8. |a) Occupation 2) evcimers
) Designation =) sciwoss
9. | Business / Office Address along
with Telephone No.
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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:
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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
