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Form No :
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 (If decided)
Address Of Enterprise
4.
Location of Enterprise
State
Select
Kerala
Code
District
Select
Code
Thehsil/Taluk/Mandal
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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 will be an Anciliary(Yes-1,No-2)
Select
Yes
No
9.
Proposed Schedule of Installation of Plant and Machinery (mm/yyyy)
10.
Type Of Organization
Select
Proprietary
Hindu Undivided Family
Partnership
Co-Operative
Private Limited Company
Public Limited Company
Self-Help Group
Others
PRODUCTS AND ACTIVITY OF ENTERPRISE
11.a.
MAIN MANUFACTURING / SERVICE ACTIVITY
11.b.
PRODUCTS TO BE MANUFACTURED/SERVICE TO BE PROVIDED
12.
Investment in Fixed Assets
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
13.
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
14.
POWERLOAD (ANTICIPATED) H.P /K.W.
H.P
K.W
15.
(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
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
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
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
EMPLOYMENT
16.
MANAGEMENT AND OFFICE STAFF
SUPERVISORY
WORKERS
ENTREPRENEURS' PROFILE
17.
ENTREPRENEURS' PROFILE (OF ALL PARTNERS/DIRECTORS OF THE ORGANISATION)
NAME
GENDER
CATEGORY
KNOWLEDGE LEVEL
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
18.
EXPECTED SCHEDULE OF COMMENCEMENT OF PRODUCTION / ACTIVITY
(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.