a8 ones sfter Ft Gear 3 fare ore Atal Pension! ATAL PENSION YOJANA (APY) - SPL eY SUBSCRIBER REGISTRATION FORM %, The Branch Manager, Dear SiMadam, | bereby request that an APY account be opened in my name under National Pension System (NPS) as per he particulars given below: * Indicates mandatory fields. Please fil the form in English and BLOCK letters 4. BANK DETAILS: Bank Ale Numbert Bank Name" ‘PERSONAL DETAILS: Name ct Appcant FullNane Date of Birth* Age ‘Mobile No Email aaa Maries ves itmartied, spouse name is mandatory ‘Name of Spouse ‘Aadhaar Nominees Name” otras Nanine' eabonship wth subscriber ‘tional Detain ase nominee is Minor Dae of ath t|m|m|s Guard's Name ‘Whether beneficiary of other statutory social security schemes ‘Yes ‘Whether Income Tax Payer Yes PENSION DETAILS Pension Amount (Please tick(,)) * 1000 2000 3000 4000 5000 Contribution Amount Monthly) ry trey eek ay aren nna te neo ma {in Rs.) br transacton delayed ot eflectd tal fret balance | woUd tot ha he bank (To be filled by the Bank) resgonsble.| so underate to dpost te addional amout gate wih penal fheeon Declaration & Authorization by all subscribers I mae the prescribed elgbty crtera for asitance under APY and have read and undertod the ts an condos of he Scheme | heey agree tthe same and cir thal he nfomatonfurshed by me ste ad cect tothe bes cf my knowdge and bebe. | undertake to medial eorm he bark ofan change in he above ifeaatn furesnedby me. Further ldo ot hol any pesxsting account unt NPS. unertag ta shall be ly aber submsion ny false nae formaton ‘or docurents. have readfoen expand and have ndersood fe APY guelnes. | ure agree fo be bound by he es and cndton f prov fseoes under he ‘heme as approved by PFROAGOM of lia. Signature/Thumb Impression of Subscriber (LT incase of male and RT! incase of female) ‘ACKNOWLEDGEMENT - SUBSCRIBER REGISTRATION FOR ATAL PENSION YOJANA (APY) {Tobe filled by the Bank) Name ofthe Subscriber RAN Number Guaranteed Pension Amount Periodicity of Contibution Monthly Contribution Amount under APY (inks) Name ofthe Bank Bank Branch Receiving Oficer’s Name: Date of Receipt of Application: ‘Stamp and Signature ofthe Bank pra a drt ae a neh sora de eran 4 ar ae fra & ora ort weare