APLICATION FORM
I Name and Address for Correspondence of the Promoter/Industrial Undertaking in Full (BLOCK LETTERS)
Name of the
Undertaking
Promoter
Area
Town
Tehsil/Taluk
District
State
Pin Code
Telephone
Telex
Fax
Cable
II Registrar of Companies
Registration No.(if registered)
III Status of the Promoter/Industrial Undertaking
(1) Status of the Promoter/Industrial Undertaking (Please tick the appropriate box)
Central Government Undertaking Private Sector Undertaking
State Government Undertaking Individual Promoter
State Industrial Development Corporation Assisted Sector Undertaking
Joint Sector Undertaking Co-operative Undertaking
(2) Indicate whether this proposal is for (Please tick the appropriate box)
Establishment of a New Undertaking Infrastructure
Effecting Substantial Expansion Hospital
Manufacture of New Articles Institution
IV Location
(1) Location of the proposed undertaking
Place/Town
Tehsil/Taluk
District
State
Pin Code
(2) Please indicate whether the Proposed Location is
(a) Within 25 Km from the periphery of a City having population above one million according to 1991 census
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Yes No
(b) Located in an Industrial Area/Industrial Estate designate up prior to 25.07.1991
Yes No
(c) Whether proposed Land is Govt. or Private Govt. Private
V Items(s) of Manufacture : In case of more than one item supplementary sheets may be used.
(1) Item of Manufacture*
(a) National Industrial Classification of all Economic Activity(NIC), 1987
NIC No.
(b) Item Description
(c) Proposed Annual Capacity
(d) Existing Capacity
(e) Total Capacity after Expansion
(f) Unit of Capacity
(2) Description of Activities to be Undertaken (if, no manufacturing envisaged)
(3) By-Products/Co-Products
NIC No.
Item Discription
Proposed annual capacity
Existing capacity,(if applicable)
Total Capacity after expansion
Unit of Capacity
NIC No.
Item Discription
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Proposed annual capacity
Existing capacity,(if applicable)
Total Capacity after expansion
Unit of Capacity
NIC No.
Item Discription
Proposed annual capacity
Existing capacity,(if applicable)
Total Capacity after expansion
Unit of Capacity
(4) Raw Material (Including Components, Intermediates and Packing Materials) per annum
ITEM (S) QUANTITY UNIT VALUE
VI Whether the Item(s) of Manufacture/By-Product/Co-Product is covered in Schedule-I (Reserved for Public Sector),
Schedule II (Under compulsory Licensing) or Schedule III (Reserved for manufacture in Small Scale Sector) of
Notification No. 477(E) dated-25.07.1991/ as ammended from time to time.
Schedule I Schedule II Schedule III
Yes Yes Yes
No No No
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VII Investment Existing Proposed
(Amount in Rupees) (Amount in Rupees)
(a) Land (for rented premises capitalised
value of the same to be indicated)
(b) Building
(c) Plant & Machinery
(i) Indigenous
(ii) Imported
(a) CIF Value
(b) Landed Cost
(iii) Total [(i) + (ii)b]
VIII Financing Pattern Existing Proposed
(Amount in Rupees) (Amount in Rupees)
Total Equity
(i) Resident Indian
(ii) Non Resident Indian
(iii) Foreign
Total Borrowing
(i) Public Financial Institution
(ii) Public Borrowing
(iii) Other Sources
Promoters' Contribution
(1) Whether Foreign Technology Agreement is Envisaged (Please tick appropriate box)
Yes No
(2) Whether Foreign Investment is Envisaged (Please tick appropriate box)
Yes No
IX Employment (All figures in number)
Existing Proposed
(a) Supervisory
(b) Non-Supervisory
(c) Total
X Expected Date of Commencement of Commercial Production
Date Month Year
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XI Required Attachments
(a) Last Three Years Balance Sheet of Company or Institution or Person
(b) Details of Income Tax paid during last three years
(c) Clearance required for establishment of Project
(d) Details of viability of projects (Appraisal Report of Financial Institution/Bank may be enclosed.
(e) Please enclose Bank Draft of Rs. One thousand in favour of Department of Industries, Govt. of Bihar, Patna
Declaration
I/We hereby further declare that the above statements are true and correct to the best of my/our knowledge and belief
Signature of Promoter (s)
(Name in BLOCK Letters)
(Designation of the Promoter)
Place ..............................
Date Month Year
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