Form - 1
(See Rule - 4 (2))
COMMON APPLICATION FORM
STATE INVESTMENT PROMOTION BOARD - SINGLE WINDOW CLEARANCE
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Part – 1- A
INVESTOR'S INFORMATION
1. Investor’s Details
1.1 Name of Investor/Company
1.2 Address of Regd. Office
Tel.
Email Website
1.3 Name of Chairman/M.D.
Address
Tel.
Email Website
STATE INVESTMENT PROMOTION BOARD - SINGLE WINDOW CLEARANCE
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Part – 1 – B
PROJECT INFORMATION
2. Project Details
2.1 Name of Unit
Address for Correspondence
Tel. Fax Email
2.2 Nature of Proposed organization (please tick)
1. Proprietary 6. Co-operative Society
2. Partnership 7. Public sector
3. Pvt. Ltd. 8. NRI
4. Public Ltd. 9 FDI
5. Joint Sector 10. Others
2.3 Date of Incorporation of the Company.
2.4 Regd. No.
2.5 Name of M.D./ Director with complete address &
Tel. Fax Email
(1)
(2)
(3)
2.6 Local Office [contact person] Name
Address
Tel. Fax Email
(1)
(2)
(3)
2.7 Registration for the Project.
(1) IEM No. Dt. Valid up to
(2) Udyam Aakansha No. ------------------- Dt ---------------------- Valid up to ----------------
STATE INVESTMENT PROMOTION BOARD - SINGLE WINDOW CLEARANCE
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2.8 Project Status (Please tick)
1. New Project 2. Expansion 3. Diversification
2.9 Nature of Activity (Please tick)
1. Manufacturing / Assembling 2. Processing
3. Job Work 4. Repairing / Servicing
2.10 Location of the Project. (Proposed)
2.11 Items proposed to manufacture
Sr. No. Name of product NIC code Capacity/ per year (Unit)
1.
2.
2.12 Details of By- product
Sr.No. Name Quantity per Year (Unit)
1.
2.
3.
2.13 Requirement of Raw material
Sr. No. Name of Product Name of Raw Material Yearly Requirement
Unit
STATE INVESTMENT PROMOTION BOARD - SINGLE WINDOW CLEARANCE
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2.14 Estimated Project Cost (In Lakhs)
1. Land Rs. -------------------------------------------------------
2. Land Devp. Charge Rs. -------------------------------------------------------
3. Building Rs. -------------------------------------------------------
4. Plant and Machine Rs. -------------------------------------------------------
5. Ele. Installation Rs. -------------------------------------------------------
6. Other Rs. -------------------------------------------------------
(A) Total Rs. -------------------------------------------------------
(B) Working capital . Rs. -------------------------------------------------------
Grand Total (A) +(B) Rs. -------------------------------------------------------
2.15 Proposed Means of Finance
1. Equity Rs. -------------------------------------------------------
2. Internal Accrual Rs. -------------------------------------------------------
3. Public Issue Rs. -------------------------------------------------------
STATE INVESTMENT PROMOTION BOARD - SINGLE WINDOW CLEARANCE
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2.16 Proposed Employment
Sr. No. Particulars From the From out of State Total
State
1. Unskilled
2. Skilled
3. Supervisory
4, Managerial
Total
2.17 Project Completion Schedule
1. Month & Year
2.18 Any other Information
STATE INVESTMENT PROMOTION BOARD - SINGLE WINDOW CLEARANCE
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Part- 1-C
PROJECT REQUIREMENT
3. Land
3.1.1. Private land
(1) Details of Area
(Khasra No./ Rakba Hect.)
(2) Village
(3) Tehsil
(4) District (Chhattisgarh)
3.1.2. Government land
(1) Details of Area
(Khasra No./ Rakba Hect.)
(2) Village
(3) Tahsil
(4) District
3.2 Water
(A) Water requirement for project ---------------------------------------------------- Million Cubic Meter/Year
3.2.1. Source of water
(1) Village
(2) Tahsil
(3) District (Chhattisgarh)
3.3 Power
(1) Requirement of Power KW/ HP
STATE INVESTMENT PROMOTION BOARD - SINGLE WINDOW CLEARANCE
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Part- 1-D
DECLARATION
I, Shri/Smt. ......................................................... S/o/W/o Shri .........................................................
Aged ..................... Residing at ......................................................... (Designation)..................
......................................................... of M/s ......................................................... Regd office at
......................................................................................................................................................................................
...................................................................................................................................................................
hereby declare that the information furnished by us to the SIPB/DIPC Dist. ................................... ,
Govt. Of Chhattisgarh. by our company in this Common Application Form are true to the best of my
knowledge, belief and record. We indemnify the above agencies or any other agency under the jurisdiction
of Govt of Chhattisgarh from liabilities of any nature that may arise due to the decision taken based
on the information contained in this application form which may be inadequate, inaccurate, erroneous
etc. and the management of my company assumes complete responsibility in this regard.
Further, my company undertake to provide any additional information or clarification as required
by SIPB/DIPC ……………………., Govt. of Chhattisgarh or its agencies during and after processing of
our application.
We undertake to pay the fees/charges payable to Govt of Chhattisgarh and its agencies
as prescribed under the rules for according approval and charges fixed for water, energy, etc. and
other charges fixed by the Govt. of Chhattisgarh from time to time.
We understand that this single window clearance facility through SIPB/DIPC is to assist our
company in getting statutory clearances expenditiously. We indemnifty. SIPB/DIPC, Govt. of Chhattisgarh
and its agencies from any liabilities whatsoever.
Place
Date ............................................................................................
Official Seal of the Authorized Signatory .........................................................
Company Name ..................................................................................
For ......................................................................................
Designation ........................................................................
STATE INVESTMENT PROMOTION BOARD - SINGLE WINDOW CLEARANCE
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