Application Form For Renewal of SAS Agency

Directorate of Small Savings & Lotteries, Goa
APPLICATION FOR RENEWAL OF SAS AGENCY
From:-
Name :______________________
Address : _____________________ _____________________
Phone No. ____________________
Dated: _______________________
To
The Director,
Directorate of Small Savings & Lotteries,
Serra, Bldg. Nr. All India Radio,
Altinho, Panaji, Goa. 403 001
Sub:- Renewal of SAS Agency No. NSO/DSSL/SAS/________
Sir,
I hereby request you to renew my SAS Agency which is expiring on __________________________________
I am enclosing herewith original Certificate of Authority and last renewal order for necessary endorsement.
I declare that I am not employed under the central or State/Union Territory Government.
I declare that none of my relatives ( i.e. Husband, Legitimate Child, Step Child, My Father, Step Father, Mother/Step Mother, Brother/Step Brother, Sister/step Sister, Father in Law, Mother In Law, Brother in Law, Daughter in Law ) is employed under the Central or State/Union Territory Government.
Total collection from last renewal to till date is __________________
Thanking you in anticipation.
Yours faithfully,
Encl: As Above :