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Form No :
(To be filled up and submitted to the District Industries Centre after commencement of production/activity[ The rows which have been repeated need to be filled only to the extent that actual details on commencement vary from those in Part I ])
ENTREPRENEURS MEMORANDUM NUMBER(Part I)
Select District
Directorate
Thiruvananthapuram
Kollam
Pathanamthitta
Alappuzha
Kottayam
Idukky
Ernakulam
Trissur
Palakkad
Malappuram
Kozhikode
Wynadu
Kannur
Kasaragod
DATE OF ISSUE
MONTH OF COMMENCEMENT OF PRODUCTION/ ACTIVITY (MM/YYYY)
PERSONAL DETAILS
1.
Name Of Applicant
2.
Communication Address
Address
Website
Telephone Number
Fax Number
Cellphone Number
E-mail
Permanent Address
SAME AS THE ABOVE
Address
Website
Telephone Number
Fax Number
Cellphone Number
E-mail
NAME AND LOCATION OF ENTERPRISE
3.
Name Of Enterprise
Whether the Enterprise has been registered under PMT/ Filed EM PART II earlier
YES
NO
Address Of Enterprise
If Yes , Registration / EM No
4.
Location of Enterprise
State
Select
Kerala
Code
District
Select
Code
Thehsil/Taluk/Mandal
Select
Code
Panchayath/Municipality/Corperation
Select
Code
Village/Town
Select
Code
Pin Code
Ward & Buliding Number
Area(Rural-1,Urban-2)
Survey Number
CATEGORY AND ACTIVITY OF ENTERPRISE
5.
Category Of Enterprise(Micro-1,Small-2,Medium-3)
6.
Nature of Activity
Manufacture
Service
7.
Nature of Operation (Perennial-1,Seasonal-2,Casual-3)
Select
Perennial
Seasonal
Casual
8.
Whether the unit is an Anciliary(Yes-1,No-2)
Select
Yes
No
9.
Month of Installation of Plant and Machinery (mm/yyyy)
10.
WHETHER THE UNIT IS REGISTERED UNDER FACTORY ACT
Select
Under Section 2m(i)/2m(ii)
85(I)/85(ii)
Not Registered
11.
Type Of Organization
Select
Proprietary
Hindu Undivided Family
Partnership
Co-Operative
Private Limited Company
Public Limited Company
Self-Help Group
Others
PRODUCT DETAILS OF ENTERPRISE
12.a.
MAIN MANUFACTURING / SERVICE ACTIVITY
12.b.
PRODUCTS MANUFACTURED/SERVICE AND PROVIDED
13.
Investment in Fixed Assets(Rupees)
Land (Owned-01/Rented-02/Leased-03)
Select
Owned
Rented
Leased
Approx. Value
Rupees
Thousands
Lakhs
Crores
Building (Owned-01/Rented-02/Leased-03)
Select
Owned
Rented
Leased
Approx. Value
Rupees
Thousands
Lakhs
Crores
Plant and Machinery Value
(In case of manufacturing enterprise)
Rupees
Thousands
Lakhs
Crores
Equipment Value
(In case of service enterprise)
Rupees
Thousands
Lakhs
Crores
Foreign Equity , If any value)
Rupees
Thousands
Lakhs
Crores
14.
INSTALLED CAPACITY PER ANNUM
PRODUCT
QTY/Year
UNIT
1.
Select
MT
KM
SQM
LT
CUM
KG
NO
TH NO
PR
TH PR
GROSS
TH
GR
RM
TH BO
LAKH NO
DOZ
GRAMS
TH MT
KW H
MCC
CR
NS
T
NOS
15.
POWERLOAD (ANTICIPATED) H.P /K.W.
H.P
K.W
16.
(a)
(i)
OTHER SOURCE OF ENERGY / POWER [IF REQUIRED]
Select
COAL
ELECTRICITY FROM GENERATOR
ELECTRICITY FROM GRID
LPG
NON-CONVENTIONAL
NO POWER NEEDED
OIL
TRAD.ENRG./FIREWOOD
Select
COAL
ELECTRICITY FROM GENERATOR
ELECTRICITY FROM GRID
LPG
NON-CONVENTIONAL
NO POWER NEEDED
OIL
TRAD.ENRG./FIREWOOD
Select
COAL
ELECTRICITY FROM GENERATOR
ELECTRICITY FROM GRID
LPG
NON-CONVENTIONAL
NO POWER NEEDED
OIL
TRAD.ENRG./FIREWOOD
Select
COAL
ELECTRICITY FROM GENERATOR
ELECTRICITY FROM GRID
LPG
NON-CONVENTIONAL
NO POWER NEEDED
OIL
TRAD.ENRG./FIREWOOD
(ii)
If no power required,specify reasons
(b)
INDICATE ANNUAL REQUIREMENT SOURCE OF ENERGY
QTY
UNIT
Select
MT
KM
SQM
LT
CUM
KG
NO
TH NO
PR
TH PR
GROSS
TH
GR
RM
TH BO
LAKH NO
DOZ
GRAMS
TH MT
KW H
MCC
CR
NS
T
NOS
Select
MT
KM
SQM
LT
CUM
KG
NO
TH NO
PR
TH PR
GROSS
TH
GR
RM
TH BO
LAKH NO
DOZ
GRAMS
TH MT
KW H
MCC
CR
NS
T
NOS
Select
MT
KM
SQM
LT
CUM
KG
NO
TH NO
PR
TH PR
GROSS
TH
GR
RM
TH BO
LAKH NO
DOZ
GRAMS
TH MT
KW H
MCC
CR
NS
T
NOS
Select
MT
KM
SQM
LT
CUM
KG
NO
TH NO
PR
TH PR
GROSS
TH
GR
RM
TH BO
LAKH NO
DOZ
GRAMS
TH MT
KW H
MCC
CR
NS
T
NOS
EMPLOYMENT
17.
MALE(No.)
FEMALE(No.)
TOTAL(No.)
MANAGEMENT AND OFFICE STAFF
SUPERVISORY
WORKERS
18.
TOTAL ANNUAL TURNOVER(If less than one year of operation ,then expected turnover)
Rupees
Thousands
Lakhs
Crores
19.
EXPORT (if any) (in Rupees)
Rupees
Thousands
Lakhs
Crores
ENTREPRENEURS' PROFILE
20.
ENTREPRENEURS' PROFILE (OF ALL PARTNERS/DIRECTORS OF THE ORGANISATION )
NAME
GENDER
CATEGORY
KNOWLEDGE LEVEL
EQUITY PARTICIPATION (%)
STAKE IN OTHER ENTERPRISES
M
F
SC
ST
OBC
OTHERS
PH
Select
Technical Graduate
Management Graduate
Post Graduate
Other Graduate
Under Graduate
Any Other Lower
Crores
Lakhs
Rupees
Thousands
Yes
No
21.
DATE OF COMMENCEMENT OF PRODUCTION / ACTIVITY(dd/mm/yyyy)
Date
Place
This is to certify that the information furnished in the memorandum is true and correct to the best of my knowledge and belief. I / We have obtained approval / consent / license / permit from the concerned Ministry / Department of Central Government / State Government / UT Administration as per statutory requirements.