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ORDER FORM TO, The General Manager IG MINT HYDERABAD, IDA Phase II, Cherlapally, Hyderabad-500040 Please book my order for commemorative coins as per the following information:

Name of the Commomerative coin

Sno

Cost of Each Commomerative Coin Set (Rs.)

DATE:

Denomination and cost of each Coin Re.1(FSS)

Rs 2 (FSS)

Rs 5(NIBrass)

Rs 10(BiMetallic)

3200/-

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3200/-

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3200/-

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3300/-

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200/---

-250/--

-300/-

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300/-

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300/-

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10

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300/-

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11 Platinum Jubilee of Reserve Bank of India 1935-2010 (Rs.10) TOTAL AMOUNT (For both single & set of coins)

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350/-

No of coin Sets required

A set of Two coins (UNC) 1 2 3 4

100 Years of Civil Aviation of India-2011 A set of Two coins (Rs.100 QA& Rs.5-Ni-Br) 100 Years of Indian Council of Medical Research(ICMR)-2011 A set of Two coins (Rs.100-QA& Rs.5-Ni-Br) C.Subramaniam Birth Centenary - 2010 A set of Two coins (Rs.100 QA& Rs.5-Ni-Br) Platinum Jubilee of Reserve Bank of India 1935-2010 A set of Two coins (Rs.75QA & Rs.10-Bi-metallic) Single Coins(UNC) Platinum Jubilee of Reserve Bank of India 1935-2010 (Rs.1) Platinum Jubilee of Reserve Bank of India 1935-2010 (Rs.2)

5 6 7 100 Years Of Civil Aviation Of India-2011(Rs.5) 100 Years Of Indian Council Of Medical Research(ICMR)8 2011(Rs.5) 9 Platinum Jubilee of Reserve Bank of India 1935-2010 (Rs.5) 150 years of Comptroller & Auditor General of India -2010(Rs.5)

Above amount is sent herewith by D.D for Rs. --------------------/- drawn in favour of “INDIA GOVERNMENT MINT(A UNIT OF SPMCIL) Payable at Hyderabad vide D.D. No.---------------dated-------------------- drawn on ----------------------------(name of the bank and branch) The DD may be sent by Registered Post/Ack. Due only. The Envelop must be super scribed as “Application For Commemorative Coins”. Name and Postal Address :(In Capital letters) Name

Postal Address: H.No :

DIST . State : Pin code : Phone No:…………………...... Mobile No. + Email id : Note :One DD can be taken for total booking along with the order form,Last day of booking is 27.03.2013

Applicant Signature

City

, Street

Total Amount of ordered coin sets/Coins


Order form for Comm coin booking IGMH.4ede7ed7-b3a5-4c8e-bfcb-11e032438a3a