Forms

ANNEXURE-VIII

APPLICATION FOR ASSISTANCE UNDER PRIME MINISTER'S ROZGAR YOJANA 200..........

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
Village/Street :
G.P./Area : __________________
Block/N.A.C./Municipality :
P.O. :
District :
(b) Police Station :
3. (a) Address for correspondence with PIN :
Village/Street :
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
(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	Qualification secured	Qualification for which appeared in examination, but failed.

(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 along with the applications are true and genuine to the best of my 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.

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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