ORDER FORM

Booking period: 01.12.2015 to 31.01.2016

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:
Denomination of Coin
(Amount specified for each coin) Coins Total cost of
S.No. NAME / THEME OF THE SINGLE COIN (UNC) Required ordered Coins
Rs. 10/- Rs. 5/-
(Bi-Metallic) (Ni. Brass)
1. CENTENARY COMMEMORATION …… 312/-
OF KOMAGATA MARU INCIDENT
2. CENTENARY COMMEMORATION 360/- ……
OF MAHATMA GANDHI’S RETURN
FROM SOUTH AFRICA
3. 125TH BIRTH ANNIVERSARY OF ------ 312/-
JAWAHARLAL NEHRU
4. INTERNATIONAL DAY OF YOGA 360/- ……
TOTAL AMOUNT:

APPLICANT DETAILS:
Name:
(CAPITAL LETTER):
Address:

City: State:
Pin Code: Phone/ Mobile. No:
Email id:
(Mandatory to send acknowledgement / Delivery details)
DD No / Date Bank Name and
Branch
Mode of payment CASH / DD/ BANKER’S
CHEQUE
Amount in Rs.
(Tick as applicable)
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 favor 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.