Application for purchase of social security certificates

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....cation for withdrawal from Post Office Savings Bank.         (iv) Matured old certificate(s) for investment.         Total :         *Cross out, if not applicable. DECLARATIONS: 2. I hereby declare- (a) that I agree to abide by the Social Security Certificates Rules, 1982; (b) that I am of good health (see paragraph 6 below); (c) that I am not less than 18 years, and not more than 45 years of age 3[***] in evidence of which I attach the document specified at item__________ of paragraph 7 below together with a copy** of that document; @(d) that I have not previously purchased any Social Security Certificate; OR @(e) that the aggregate face value of certi....

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...._____ GBP4. I require identity slip. $5. The certificate(s) (and Identity slip GBP) may be made over to Shri/Smt_____________ agent (Authority No______________,) 1[***] GBPGBP Cross out paragraph 3, if nomination is not required.   GBP Cross out, if identity slip Is not required. For Identity slip if required, applicant's specimen signature and marks of identification must be furnished in the space below paragraph 8. $ Cross out, if the certificates and identity slip (where required) are to be received by the applicant personally. DECLARATION OF HEALTH 6. I hereby declare- (a) that I am of good health. (b) that during the last three years I have not suffered from asthma, pneumonia, spitting of blood, tuberculosis, high ....

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....f the applicant's service record kept by his employer____________(name and address of the employer) stating the applicant's date of birth as accepted by the employer; along with a letter/certificate (in original from the employer stating that he has accepted the said date of birth on the basis of standard proof. 5[(ix) A statement in Form 5 made by the applicant in the presence of the Postmaster.]   8. Social Security Certificates previously purchased by the applicant and not matured or prematurely discharged as on the date of this application: Sl. No. Certificate Number and date Face Value (Rs.) Name of Post Office where registered.   1 2 3 (i)       (ii)       (iii)   ....