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ANNEXURE-VIII
- To download the form
APPLICATION FOR ASSISTANCE UNDER PRIME MINISTER'S ROZGAR YOJANA 2000-01
Name of the Revenue District______________Name of the
Block/NAC/Municipality__________
-
- SECTION 'A'
-
- (Write in Block Letters)
____________________
- 1. (a) Name in full of applicant
:
Affixed
attested passport
- (b) Name of father/husband
:
size
in duplicate
- 2. (a) Permanent Address
:
photograph here
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Village/Street
:
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G.P./Area
:
__________________
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Block/N.A.C./Municipality
:
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P.O.
:
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District
:
- (b) Police Station
:
- 3. (a) Address for correspondence with PIN :
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Village/Street
:
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G.P./Area
:
-
Block/N.A.C./Municipality
:
-
P.O.
:
-
District
:
- (b) Police Station
:
- 4. Present
engagement/employment of parents/ :
- husband/wife
of the applicant if any with their
- names
and other details.
- 5. Name of scheduled
commercial Bank operating :
- in the
service area of applicant residing/proposed
- venture
to be located.
- (In case of Rural areas)
- 6. Name of the cheduled
commercial Banks in the :
- area of
the applicant (in case of urban areas, close
- proximity
of Bank Branches only to be mentioned).
- 7. Category to which
belongs.
- (a) SC/ST/OBC
- (b) Women/Physically
Handicapped/Minoritty :
- 8. (a) Applied during earlier years
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(If any under SEIUY/PMRY.
:
Yes/No
- (b) Whether the applicant has availed loan. :
Yes/No
- (c) Whether the applicant is defaulter of loan :
Yes/No
- (c) Whether
any family members (Husband,
- Wife/Brother/Sister/Parents availed PMRY
- Loan earlier, if yes give details
- 9. Location of proposed
project, specify.
:
-
- SECTION 'B'
-
- (Document evidence in support to be enclosed)
- 1. (a) Date of Birth
:
Day……..
Month……… Year……….
- (b) Age as on date of application
:
Years…………..
Months……………..
- 2. (a) Last/Highest academic/Technical &
Educational Qualification
- Year
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- Qualification secured
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- Qualification for which appeared in examination, but failed.
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- (b) Continuing
studies:
:
Yes/No
- (If yes, mention instruction and year of study
- and the course)
- 3. Employment Exchange and
Registration Number :
- 4.
Case Certificate(In support of caste in
case of
- SC/ST/OBC)
- 5.
Annual income of family
i.e.himself/herself and :
- his/her spouse and parents.(In case of
married
- female applicants, The income of parents-in-law)
- (Affix undertaking in Prescribed form)
- 6.
If applied earlier under SSTUY/PMRY, but
not :
- availed (mention the year and name of the Bank
- Branch)
- Section: C
- 1.
Proposed Venture(Project)
:
- 2.
Cost of the project (enclosed copy of
project
- Profile/scheme
duly signed).
:
- 3. Whether to set up on
proprietorship or partnership.:
- 4. If on partnership basis,
mention the detail
- address
of the partners.
:
- 5. Whether willing to
deposit 5% to 16.5% or
- differential
amount between loan amount and
- cost of
project.
:
- 6. Past experience on
proposed venture if any or
- support
system arranged to set up the venture.
:
- 7. Details of ED/any other
entrepreneurship
- training
taken, if any.
:
- 8. Extent of amount which
can be invested from
- own sources to implement the venture.
:
- 9. (a) Progress made in arranging land in his own
-
name or other to pledge to Bank to erect
-
structures/digging well etc. out of bank
-
finance or taking structures on rent for a loan
-
period.
:
- (b) Progress made for arranging shop/ factory
-
shed etc. for establishment of venture.
:
- 10. Name
of Bank Branch in the proposed area of
- Location
of venture contacted and discussed with
- Branch
Manger with Project Profile. Any Bank
- has
shown interest to consider Finance. (This is
- applicable
for ventures to be established In urban
- areas
only).
:
- Certified
that the information/documents furnished alongwith the applications are true and genuine
to the best of muy knowledge and belief.
-
- Place
- Date
SIGNATURE OF THE APPLICANT
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- (To be torn-out and handed over on demand)
-
- ACKNOWLEDGEMENT
-
- Received
the application for financial assistance under PMRY 2000-2001 from Shri/Smt.
……………………………………..
S/O./D./O./W./O. Shri
………………………………………….
Village ………………………..
P.O………………………..……….
P.S…….……………………….
Dist…………………………. Alongwith
………………………. Number of enclosed sheets today,
the …………………………2000.
-
Signature of the receiving Officer with designation.
-
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ANNEXURE- IX
-
- FORMAT FOR UNDERTAKING
-
- I
, ………………………………….. S/o.,
D/o., W/o.
……………………………………………
resident of …………………………….. holding
No. …………………. Ward No.
………………… NAC/Municipality/Village/Block/P.S.
……………………….. District.
……………….. in Orissa, do hereby solemnly affirm and declare as
under.
- 1. That
I am unemployed, 2. that I am not in a position to muster my own capital for the Project,
3. that i am a permanent resident of
………………………… Block/Municipality/NAC
………………………… District. Since
……………… years. 4. that the income of my family which includes
spouse does not exceed Rs.24,000/- per annum from all sources such as salary, wages,
agricultural income, business, rent, interest, pension etc. 5. That the income of my
parent/ parents - in law also does not exceed Rs.24, 000/- per annum from all sources, 6.
That I and my family members have not defaulted in repayment of loan from any Nationalized
Bank/ financial Institution/Co-operative Bank. 7. That I am eligible for financial
assistance as per criteria of PMRY. 8. That I shall abide
by the rules framed under the scheme of PMRY for educated unemployed Youth.
9. that I shall submit the progress report as may be required by the Bank/Government.
- Signature of the applicant
- Verification
- Verified
that the above contents are true and correct to the best of my knowledge and belief and
nothing has been concealed therein.
-
- Date :
Signature of the applicant
-
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