~

K 5511) (:

(5~F~5 ~~Fdoeroo6~)
(A Government of Karnataka Concern)

KSSIDC HO COpy

Karnataka State Small Industries Development Corporatio-" Ltd. tmo'!"C> ~~n

Application
1 a) Name of the Applicant ~~Fr:J;)o'~ (s) in Block L~ters
I

I N~~~N' ~o'(;.3!mf\ ~~~

of Industrial Shed I Plot

for Allotment

( 0') ~;tjQ) d~50'Ti9t!) OJ.. ""

rn

DODD
0

b) c) 2 a) b) c) d)

Male / Female Tio~ I ~~ Name of Father / Husband 30doi) I TiozZ~~;tjQ) Type of Shed/Plot Applied for ~~F ;j~",t:S ~~~ I ~~~~~ ~t:So Number of Sheds/Plot Applied for ~~F ;j~.!Jt:S ~~~ I ~~~~~ ;jO~6ri~ Industrial Estate at which applied QD;)~ ~o~ ~~~;3;)~~~ ?j~~,,~ Why this location is chosen & Locational

;
I

DO ODD

Advantages?

...~~ ;j9~~~ ;j~~oj.) '" ~ w~ t.)oj.);;;~,,~ ~;3;) ...'" ~~M~rito'~~ ? ADDRESS / ~'o';)~

a) Registered Office

b}

Factory (if existing)

c)

For correspondence!
~6~~dUC)~1'\ i
!

~O~~35d~O

~~f"~

(~~o.:1,)J~rt,d) I

4. Mark the category to which the applicant belongs (tI') ~~F~ddJ .(1) SC D D D D (5) Technocrat D (1) ~.~ (2) ~.~o

c.DCJ;S roo.!J~~eoQ)~oo~~ D 0 D 0

roQ)~~oO~~~

(tI') D

(5) 30~~ (6) ~oo~ wd6~

(2) ST (3) Ex -serviceman (4) NRI

(6) Women EnterprenuerD (7) Minority (8) General (Other) D 0

0 0 D

(3) ~~~ ~.fJ5 (4) ~~wc).!J~d~ecj.)

(7) ~~ ~O~63 (8) ~~~ (~3d)

2
Whether the applicant earlier worked in any Govt. organisation / quasi Govt. organisation / reputed companies.

~~Fo;Jd~ ~ ~o~
Name of organisation
;;::?~o:$.)..~~O.:>

~~FC I ~" ~~FC I ~~~Q;3;)~ ~o~Qi) erot;S.fC).~/'\om/'\~"a1J~? .";:)~d M~. '" " GO Designation ~t:5
GO

Salary drawn o:j~o:$.))~t:S ~e~~ ~Q

If you are already alloted with shed / plot in Govt. India Estate Please give particulars.

Industrial Estate Name Shed/Plot No. alloted

~OC;) ~~~;3;)~~ ~;;:jd) ~o?d~oD;,O~~~/N~e!!~o ;;:jO~6

No;i)~~ ~ode
7-

~~Fd t~O5C);j~~3.?~~~ o;i)~~1

N~e!!~~o2.!~o,ij;)"~d ~;jd1iQ~ M~.

a) Number & Date of SSI Registration Certificate .:>~ ..:>~ .0:). oSJO>eoo~ ~~o ;;;jo~6;:i)~ O~o5 b) Provisionally or Permanently issued 3;)3;)c()5~~~~ :;j";)c:SJo ~1'\ OJe~~1'\~ai:)e?
proposed to be manufactured / being

DDD

DD

Products

manufactured ;3QDC)o6~ ero~~!>~Q);S I ;3QDC)~ro~ti);S ero~~r19J

(1) Proprietorship (2) Partnership a) Constitution: Please Mark

;!:jo::JQO)~ : ~d?:5~ ~~.

D (1) ~!)5~ D (2) ~WCi)O~ D (3) :;j"i)~1'\ ~@::JJ;3 ~o~

D D D

(.I) (.I)

(3) Pvt. Ltd. Co. (4) Public Ltd. Co. (5) HUF (6) Co-op. Soci

D (4) ~~F"...,~5~@::JJ;3 ~o~D D (5) z.,ot;i") ~Q;)~""6 ~~o~ (6) ~~'6'i)O ~oopl D

b) Details of Proprietor / Partners / Directors

51.No.

~!)e5d I ~WCi)dd I ~~F"e~5d Q;)~dnr.i..1

~irth Place

Name
~';:Q)

Qualification

Age
lI

Da~e of

I
1

Domicile

Sh~re

~. ;;:Jo.

~a5F"~

'I:$~;;:if."
e.-Cj)

~ci);!:jJ '"

Birth
~~e, O~O6

~;r::;r::e.'!
Q

holding
~oOdJ0;5
0:)0;50

'
.~~dJT1e.'!

5. 6. 8. 9.

3
c) Name of the Managing Partners / Director / Chief Executive
~6~~Q;j5 Q;jC)~~d~ I ~6~~Q;j5 ~dF"~~5~

~~6~~F~5d ~~~
Particulars of Machinery -Indigeneous / imported c:1.?o~e~5d~KeJ ;;:Jo:SdKeoiJ debec:1.?I e~C"i)dd;?,

Name of
51.No.

New / Sec

Despn
05~O:J ~;3;) ...

hand
~;:jdJl

Name of Mfrer.

Date of

Expected

Acqun.
o::j~~MOt3 ~O~:i);)

,;.;;:jo.

~~~ 6

~r.'~dJ

~omd5d ~~d:)

Delry. Date d~~Qi)

~ot:jC)~ ON"JO~.

Total

Imported/
lIndigeneou ~~t;j';)t'I~

Imp.L.
ref.
e~d~f'I

Cost

2...~~

~~h~oD

erode~
M

11. Raw Materials Requirements 51.No. Name of Raw Annual Indigenous Require- Imported rj~. ments ~. ~T1;!6 ~~1\~i

5~

m~a,~foi ~~36~foiJ Name of the

~.~o.

Materials

Free availa 1 I
I
I

bility/quota

5.m. ~;;:Jd)

~~6~Me~

Supplier ;;:. oS;;:dJ

Price ! quota price! open market price

Remarks
~CC)

~~ ~~5~ ?,j~

Q;

12. POWER: Furnish details of power requirements in K.W.

:J~6;s6' : :J~6;s6'~r1:!6r1~~ 6~~~6~r1~~ ~~.!J.

13. WATER: Furnish details of water requirments in

Liters.
~~d) : ~~o~ ~~:!o~~ t!)~~c6'~";~ ~<I~.

10.

4
14. MANPOWER: Furnish details of manpower requirments in Nos.

~o":S~6 : ~~;;:j7'l;)dd ~Ti3,Titoc! '/.J~ ;;:jo~,~() ..,,() " M ~(>,t,.

Administrative ~~;$ ~r1FO~d:J

Technical

Skilled/Semi-skilled/ Un-skilled
~O~~dJ I ~~~O~~dJ I

Total

~O~5~~FO~~

~o~~d~o~dJ
M

t..~

15. MEANS OF FINANCE: (As. in Lakhs)

cEr'O)5'O);;:'.) ~~ (dJ't). ~tK~~

Amount already spent ~?3:JF~~o i:5ro

Amount proposed to . be spent

Total I t..~

eroti,~!>;! ~~F

1)

Own Funds

~o~ '/.)otZ~~
2) Capital promoters '/.)otZ~~ ~e~~5ti)

3)

Internal accruals
~~ ;;:io~a:SJ~nfo1J

4) Term Loans ~~~ N;)~nfo1J 5) Govt. Subsidies

;;:i~FO ;;:ia3'O)a:SJt;:I~

6)

Other Sources

",~t5 ~~nfo1J 16. PROJECT COST

Total cost of Project
~~~~OiJ t...~ ~'I..1:>F"

~et;$~

~?1 ~
Turn over
Provision for instalment of shed I

~&o~~

~~~

503.1Q;j&)~~m1'l ~~C;)!!

Profit ~Q

5
MARKETING: Please indicate the details of efforts made for marketing the products by marking (v) ~CC)~ : ero~~nfo-l~ ~CC)~ ~r3~ ~M~~ ~o.1,)~nfo-l :::J~d rud)~.!J (v) a) b) c) d) e) f) g) h) i) Tie-up with export company

d~=- ;;:jo~~oO~ ;;:j~~~T1 Q

Registration with DGS & D ~.~.o;);1:j6'. ~;!) -' ~ ~()M ~~orj~ KSIMC ~.o;);1:j6' .Q:).o;)~.~.

Stores Purchase Department ';;:jd~ :i)O~O ~~~ State Trading Corporation

~~~ ~~~one 'O'i)*Fd~~N6'

Apparel Export Promotion Council ~Q;jd~ O;)~~~~F ~~~~N6' ~%~ ET & TDC ~.~. ~~ ~.~.~.

Leather Goods Export Promotion Council ~rjO6' T1.I;>~ ~%~ Others please specify ~;3d :Jojd M~.

Please indicate whether your proposed unit comes under any of the items specified by marking (tI) against the appropriate type ~~e, ero~eh;3opI~5~ ~e.iF\~ oi1'CJ~ f'l)o:;~ ~edJ~~ wo~~~ 1) Electronics especially import substitution items. ::J~e~Q;J'O)F\ ~~ 2) ~~r1e.i ~~~F\ wd~~~ ero~6~. indigenously developed new ero~~r1e.iJ. (tI) f'I)~~~ ~~5 ;tJ;)eo.!J :

Technically sophisticated items including new process/designs/products lince of products in the country. ~~ ;;:OMe~;3 ~~r1~

~eo ~d;3~~o:11e e~~o", ~[:3.!J~ ero~~ ;30~t3;)~ ~oo~

3)

Export-oriented

units 50% minimum export obligation. d~

d~ e'Q;)O;3opI~5r1e.iJ (~e. 50 5~~ 4) Pharmaceutical ~~~r1~~ 5)

and pesticides with preference for import substitution. ~~Q 030>M ~;:;:;~~5r1e.iJ. raw materials preference being given to import 5~ ;!O;)~a..

;;:O;!O;)f..3oi1'CJf'I)~ ~~r1~~ ~~6~~OO~

Chemicals-Final ~~~r1~~

consumer items, Chemicals-industrial

substitution items. ;;:O;!O;)f..3oi1'CJf'I)~ ~~r1~~ ~~6~~OO~ ~~dJ ~e.i~~dd o;);!O;)~~5r1e.iJ ~~dJ I tmc;,

6)

Light Engineering consumer products including components. ~[:3 ~r1r1~ ~eo ~f'I)d o2f,~~OOn6' ~e.i~OC)dd ero;3~r1e.iJ.
"'0(

7)

Leather and Leather based units. ~~F ~:5:? ~QCJO;3 ero~6~r1e.iJ.

8)

Food based Industries ~d ~O;3 ero~6~r1e.iJ.

19) If yours is a chemical or other pollution prone industry I please indicate proposed arrangement to dispose treatement of effluents PL. indicate PCB Licence ref. N~P;; O;)~o.1J0;)5 ~tPQ;Jt) ~~~{,~d tmo~om1'l~~ ~o~ ~{,~~Titoi ~~~{,~o.1J~ ,;:O~O,;:~ I Mt;!l:i)w;)5~
ZJ~ (\.~~O.!J

.!J.!J~ orJdQ;Jt)~1'I ';:o:j {, o.1J~ " ~~.!J.

20) Earliest probable period of time after allotment of shed by which applicant can start production. ~~~ i$ot.!~~z::S ~o;!d ero~z::S~o.1:>~ ~dottJ;;;:~ r.je~7\:)~ 5N~ ;;;:~0.1:>.

17.

Immovables covering details like land and building 2;$;;:;::;~~ ~~ 5~~nr.-!O;5i$ ~Qjdnr.-!~r.-!MO~'J,CC)":.n~ Address
:Je.';);;:j

Other Assets ;3~ ~.tJr1fo1J J

Personal Liability
~o;td 2.jC)Q6~71~

Location ~9 '"
Date of Acqn.
MOtZ ON;)O~

Cost

~~
Present Value
~;;:j5~~ ...~ Are you alan IT/WT assessee? If so please furnish

details of Tax paid for past three years.

~~~ f:5CC)o:i:) ~;3.) f:5~ $O~CC)dO;)l'IdJ~O;)? WCJl'ld!J5r.'d
QM

~dJ

~~F"7ito"!J Q:J;)~~~~d M

$O~o:i:) ~~d

~~~.

Two references of respectable well placed persons with address and telephone No.
OJ;;l)e, o;:!o~aiI;;)dJ~ w;,T1.r&> t;ilC)d~ro ~dJ n('Q)6 w;,T1.r&> ~';~;3 ;tjO~6 .;r:~. ~6~ne.'! ;;)~;tj

Particulars of payment of EMD/application fee. ~oK~ ~e~~ ~E'Q)/~~F" ~e.>c o;j;)~'; ~t30 .:J~dK~.

Amount
~'I.)~ru

Receipt No.
d.!Je~ ;rjO~6

Date

Code No.
~O~~;$ ~O~6

=:JDDDD D DDDD
SC/ST
Q;3.~.1Q;3.Q;30.

o~o~ 000000
GENERAL
;!~

ODD

a)

Payment of Application Fee (Non-refundable) ~dJQ;J;)~~QD;)nd~*C~ ~~F" ~~1I

As. 25-00 + Tax ~o~

As. 50-00

50-00 + Tax ~o~

b)

Payment of Scrutiny fee (non-refundable) ~dJ;!J;>~~QD;)nd ~o!>~~~ ~~1I

As. 200-00

c)

Payment of EMD. ~on1Z ~~~~~ Q;J;)~~ As. 500-00

d)

Sheds in Industrial Estate not covered under Bangalore agglomeration area (covered by DLAC) refundable.

As. 500-00

tjon'o1J;)d,) ~o~ ~~~

~*C~mF\ (~~ ~~d

~~dd~o~ ~~~~
~o~~ ~~~~ ~6~~

'l.)dJ~dJ) ~dJQ;J;)~~QD;)ru~otPdto.

22. 23. 24. As.

7
ii. Sheds in Industrial Estate covered under Bangalore 2500-00 2000-00, 1500-00 1000-00 Deposit I' of KSSIDC Ltd payable at Bangalore ~.~. be submitted) ~~5 t..~?"5~~. 5000-00

agg lomeration

(A type shed)
,~

.:) ~oo

~~~

area (covered

b y SLAC ) refundable.

4000-00

~ ~do ~~~
~ ~do ~.;J~

?"5o71~o:>~o~ ~~ci1~ ~eoo ~o~ ~AjC)CX:~:J~~ ~(J~71C)rI( O';Jt;$ ~~o CX:o~~;;:!:JJ~ci1 ~ lJ~ 'Z.)0:>~0,)) ~ w ~... ~0:>~~~oD&1T\)~O3~. e) Payment of Electricity ~~~~ ~~~ D.D. drawn in favour

ed) ~ ~dO ~<>"

__:J0,)6~ (Note: ~~~ 25.

Crossed

: ~.~;tj6".~;tj6" .~.~..!I. of submission

():JJ~r;36' o:!d~rI of application

?"5o71~O~1!;!, ~~~oD&1T\)~ Notification ~5~~ci1

Particulars

reference w~~~ ~~ O~o5

and date: ON;)o5

~~F" ;;:!1!;!,~ci1 :J~d71~

Date of issue of application: ~~F" o:!~o')Mor3 Date of submission ~~F" ;;:!().!IO ON;)o5 of application:

Documents to be submitted in duplicate

~~~c:$,:)~ ;;::~;;::~~e;)~ ~~~r1~

1) 2~ 3)

Application OJ~F"~~50:> t. Detailed

form ~

~~F" '"tJddo. SSI Certificate report issued by or P&C SS I ~~oo~ & provision o:!~ cash-flow towards ~(J~. ~do OJ~~o ~~o()5/:;jOIci1o

Provisional/permanent project

comprising

performance projection profitability repayment of shed cost. ~710,) ~~~ ?"5~~d:>~~~ 4) w~~b3 Q ~~~!!719~9MOr3

~oD&1F"zjd~, ~Qb~~~ :J~d~o

~;!) ~~t;$~

...

Approval from state level Committee or Department of Electronics in case electronics items based production. ~~~OJe6" ~~~oD&1Q"i)O3 WO6~~rI~~ 0';Jt;$6~J ;;:!:JJ~ ~~~ ~~~OJ~ ~~~F"~o~OJoo Foreign collaboration agreement An undertaking preference. ;;:!(Jeci1/o:!.~./ that local persons o:!.o:!o. t;$~o71 oo.~ ~(:i)~~o~. if any. SC/ST will be gien

5) 6)

:J~~b ;;:!CX:~e710 t..o:!oo ~N;)od/;) ~o~. OJ Q

S!.

,,"

OJ~t3.)~'Z.)~~zj(J~.

..

7)

l,;ertificate from applicant belongs ~~F"C;)do:> o:!.~./

competent authorities in case to SC/ST Ex-serviceman/technocrat.

the

o:!.o:!o./ OJ~ 13 ~~5d:> 303,t;$O';JrlOt5 ~O~,3 if~ ~ Q , u machinery !(J;;:!.)~ ~~. -P.S. deed. ~~rIC)O~ o:!3,. ~ of Assn. ~~F"5~ ~ ~~ & Articles Layout plan.

8) 9)

~{p~5d~ o:!~. Line Diagram indicating ci1o~AjC)~~, ~~C;)O~ ~o:!~ci1~ In case of PIS concern WO~oD&1o() """

10) In case of a Co-Memorandum

w~~~ 50o:!OJoD&1r19,1!;!, ~~O';J6r30 ~~~.!I~e~~ .

The particulars furnished above are true and correct to the best of my belief and knowledge
~~O~ :;;~dnfoiJ ~;36Q;ji)O~ Q;i)~ ~~ ~('Q)F ~o~~ w;)M :!'foiJ~()~ai> ~5;)d ~oomo~ ~"d.:>~d.

Name in Block Letters ..,

Signature of the Proprietor I Partner I Director

~;;:O:> o~ ~~drlr.iq,
Note:

~!J~o:> I ~~~do:>

I OJdF"e!!~d ;;:00

Please note the incompleted application without required enclosures and leaving blank any of the colu~n is liable for rejection.

u~~ : ~O~~F"~~O ~rl36 ~~drl..,l,) ~~~~l'IdO ~~

';d~O;;:~ru~d.).

~~~OdJ;)

~o~rlr.i~ ;!,:)o~;;:de "qo:>~ ~~F"rlr.i~

~ -

26.

FOR OFFICE USE ONLY

c'~~O~ ero~~~r('50~~
1) Project report sent to 8181 for feasibility report on ;;:j.t.~~. ;;:j~ ;;:jO~~6'!";) ~dOnCJ1't,~~~~~dOoi)~ 59Jlo.!JOO~O5. 2) Feasibility report received or not received? ;l:jO'ljjC)~6:!C) ~doQ:t).) ~oOd~~ 3) ...~~? Yes No

Date
O~o5

DDDDDDDD
Date
M

~O,) ~~

ON;Jo5 DDDDDDDD

Remarks of 8181 on the project report o1IC>~tS~ ~dOo.1) ~~ ;I:j.t.~~.;l:jo. ~~~0.1)

4)

Recommendation

of the interview committee

;l:joO!!F~ ;I:j~~o.1) !>~d~7i9J 5) Recommendation of the interview committee

~Od~F~ ~:;:;:;~OiJ ~Oi:iCJd~ne.iJ j 6) Date of SAC meeting and decision ~~~ 7) ~3d~ ~;:;:;~ ~~~ ON;)O5 ~~ ... ~~~F~ under which allotted
M

DDDDDD DODD DD DDD

Receipt No.
d~~O ;!:jO~ 6

Shed allotment -Scheme

~<>~ .x:o?!~ -cD&>~ ~~~~cj.)<!) -Shed / plot type -~~~

.x:o~~cD&>nd?

I ~~~!!~ ~tjo

-Shed/plot number -~(>~ 8) I N~e~o:S ;!:jo~"

EMD amount to be refunded in the case of shed not allotted ~(>~ a50~~om/'o~O~~ ~dJ~~';omTi~511 o:SJi>~~ro

Date
O~o5

Amount
~t.)~ro

9)

Recommendation ~dJ;;jC)~';~ ~~d;;;.,

of refund

10) EMD refund -Voucher No. and Date

~or\~ ~~c6' ~~~~ ;;;:0~6 ~~ ~roo ~Q;)Q:j';)~'; .';)~d

003;)05

-Cheque No. and Date

-~C6' ;;;:0~6 ~~ 003;)05

-Despatch reference
-dQ:jO)~ erod~~ M

--

MANAGER (IES)

DY.CHIEF MANAGER (IES)

CHIEF MANAGER (IES)

~6~~~~ro (t.~.)

ef\)~~~6 ~6~~~5dJ(~.~.)

~~6 qj6qj~~5Q) <t.qj.)

~.~. ~o. 1'0-9756/

Government

Press,

Peenya,

Bangalore

-58

KARNATAKA STATE SMALL INDUSTRIES DEVELOPMENT CORPN. LTD ( INDUSTRIAL ESTATE, RAJAJINAGAR,BANGALORE-560 044 )

SUPPLEMENTARY APPLICATION FORM TO BE FILLED IN PERSON IN BLOCK LETTERS BY THE APPLICANT: I. Details on the Entrepreneur / Firm applying for the shed / plot IS THE APPLICANT :
Please tick the Appropriate column YES YES YES YES YES YES NO NO NO NO NO NO

a) a first generation entrepreneur b) woman entrepreneur c) belongs to SC/ST category (enclose an attested copy of the certificate issued by the competent authority) d) differently abled category (enclose an attested copy of the certificate issued by the competent authority) e) an Ex-serviceman (enclose an attested copy of the certificate issued by the competent authority) f) a Foreign repatriate bringing in Expertise. If YES, provide details g) Is the applicant an NRI h) a local entrepreneur. (Whether residing in Karnataka for the past 5 years or more) ( enclose Domicile Certificate ) i) technically qualified intending to start the unit in the field of his expertise. (enclose the relevant Degree Certificates, attested copies) j) does the applicant have any previous work experience connected to the present project. (If so, enclose experience certificate) k) Has the applicant availed any benefit under PMRY Scheme. If so details. l) Has the applicant been allotted a shed / plot in any of the Industrial Estates of KSSIDC. If YES, details.

YES YES

NO NO

YES YES YES

NO NO NO

..2.. m) Have any of the family members ( means where the applicant is an individual, or a firm, his /her spouse, children and partners ) already allotted a shed / plot OR applied for shed/ plot in any of the Industrial Estates of KSSIDC/KIADB. If not an affidavit notarized(as per the format enclosed needs to be submitted on a Rs.100/- stamp paper) If YES, details.

YES

NO

n) If the applicant has been allotted shed/plot by either KSSIDC /KIADB has the same been fully utilized / partly utilized for the allotted industrial purposes. If YES, details.

YES

NO

o) Has the applicant been allotted shed /plot by either KSSIDC / KIADB and have transferred / changed the constitution of the industrial property outside specified family members (that is except spouse and children) or have rented out such shed / plot. If YES, details.

YES

NO

II. PARTICULARS FOR THE PROJECT FOR WHICH THE SHED / PLOT HAS BEEN APPLIED FOR ALLOTMENT (TO BE FILLLED BOTH FOR EXISTING AND NEW PROJECTS. Rs. 1. Project details I ) Project cost Rs. ii) Own investment Rs. iii) Borrowings and Rs. iv) Sources there of TOTAL 2Constitution

Proprietorship

Partnership

Pvt.Ltd.

..3.. 3. Product classification Food Electrical Engineering Chemical Textile Packaging Garments Electronics Printing Pharma

Plastic Medical Eqip Specify Others 4. Infrastructure required for the project

iv) Covered area iv) Open area iv) Power requirement- H.P iv) Monthly water requirement (Ltrs) 5. Employment Skilled : generation: (No. Unskilled : of employees in Managerial : the unit) Male : Female : 6. OTHER DETAILS: a) In the case of the applicant applying for sheds, is the entrepreneur willing for payment of 99 % of shed cost upfront within 45 days of allotment. b) Is the project report enclosed c) Is the SSI Registration Certificate enclosed d) Is the product an import substitution. e) Is the product export oriented. f) Is the project labour intensive. g) Does the project generate effluents and air pollutants. Is there hazardous waste?. h) If yes, has the unit has made any provision in the project for waste treatment before disposal. i) Whether the project is water intensive ?. Water consumption details per day. j) Whether the project is Power intensive. k) Is it an ancillary to any public sector/ pvt. sector large/ medium unit. 7. Financial details

YES YES YES YES YES YES YES YES YES YES YES

NO NO NO NO NO NO NO NO NO NO NO

i) Details of Cash flow (Separate Statement to be enclosed) ii) Details of average Debt Service Coverage Ratio (Separate Statement to be enclosed) iii) Is the financial viability study of the project made by any financial institution. YES / NO If yes, enclose report

..4.. 8. IF THE APPLICANT HAS AN EXISTING UNIT, THE FOLLOWING DETAILS TO BE PROVIDED. I) Does the applicant have an existing unit presently running successfully in private premises with a need to shift from the existing location. ii) Detailed addresses of the present
location and ownership details. (Copy of Rental agreement to be enclosed if applicable.) (iii) Details of workforce employed i) Skilled ii) Unskilled iii) Managerial iv) Male v) Female ISO 14000 BIS

YES

NO

(iv) Whether the unit has any certification

ISO 9001

Others specify: (v) Whether there is tie up with any foreign promoters. If so, furnish details.

YES

NO

(vi) Whether there is tie up with any local/ MNCs/ large Industries. If so, furnish details.

YES

NO

(vii) Furnish details of VAT / MODVAT / Sales Tax Registration. (Copies to be enclosed) (viii) Furnish copy of the SSI Registration Certificate (PMT ) (ix) Details of annual turnover with audited statement and PAN NO./TAN NO. for the last two years be enclosed. X) Whether it is registered as an export unit or is a deemed exporter. Details to be furnished along with the certificates.

SIGNATURE OF THE APPLICANT.

C/MYDO/CHE LIST 2

AFFIDAVIT
I / We ------------------------------------ S/o, D/o ---------------------------------aged about ---- years residing at No.------------------------------------------------------------------------------------------------------------------ do herby , solemnly declare on oath as under: That I / We are applying for an allotment of Shed / Plot at Industrial Estate -------------------- against Notification No.---------------------- dated ----------Issued by the KARNATAKA STATE SMALL INDUSTRIES DEVEOPMENT CORPORATION LIMITED. Whereas, That, I / We do hereby declare that, I / We or Our family members (Means where the applicant is individual or a firm, his or her spouse children and partners) have not applied for allotment of Sheds / Plots for the same notification through other application. That, I / We hereby declare that, I / We or our family members / partners have not been allotted sheds / plots by the KARNATAKA STATE SMALL INDUSTRIES DEVELOPMENT CORPORATION LIMITED any where in Karnataka since 1960 at any point of time. That, the information declared above are true and correct to the best of my knowledge. In case, if the above declaration is found to be false, the allotment made in my / our favour is liable to be cancelled in addition to forfeiture of EMD and other amounts paid by me / us to KARNATAKA STATE SMALL INDUSTRIES DEVELOPMENT CORPORATION LIMITED.

DEPONENT
Place : Date : Identified by me Advocate No. of Corrections. Sworn to before me