APPLICATION FOR ASSISTANCE UNDER PRIME MINISTER’S ROZGAR YOJANA 2005-06 

Name of the Revenue District.

 

:_________________

Name of the Block/

NAC/ Municipality.

 

:__________________

  Section –‘A’
                                        (Write in Block Letters)

1.

a)

Name in full of applicant.

:

__________________________________

Affix attested passport size photographs in duplicate.

 

b)

Name of Father/Husband.

:

__________________________________

2.

a)

Permanent address

:

 

 

 

Village/Street

:

______________________G.P./Area_________________

 

 

Block/NAC/Municipality.

:

______________________    P.O.    _________________ ______________________

 

 

District.

:

______________________  Pin ______________________

 

b)

Police Station.

:

_______________________

3.

a)

Address for correspondence with PIN Code:

 

 

Village/Street

:

______________________G.P./Area________________

 

 

Block/NAC/Municipality.

:

______________________    P.O.   _________________ ______________________

 

 

District.

:

______________________  Pin ______________________

 

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 Banks operating in the Service Area of applicant residing/ proposed venture to be located. (In case of Rural areas)

 

:

 

________________________________________

6.

Name of the scheduled Commercial Banks in the area of the applicant residing/location of the project. (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/Minority

:

_______________________________

8.

a)

Applied during earlier years, if any under SEEUY/PMRY.

:

Yes/No  _______________________________

 

b)

Whether the applicant has availed loan.

:

Yes/No  __________________________________

 

c)

Whether the applicant is defaulter of loan.

:

Yes/No  __________________________________

 

d)

Whether any family members (Husband/ wife/ Brother/ Sister/ Parents) availed PMRY loan earlier, if yes, give details.

:

 

9.

Location of proposed project specifies.

:

 

  Section-‘B’

(Documentary 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 (If yes, mention Institution and year of study and the course.

:

Yes/No _________________________________

 _______________________________________

3.

Employment Exchange and Registration Number.

:

_______________________________________

 

4.

Caste Certification (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 applicant, the income of parents-in-law, (Affix undertaking in prescribed form).

:

_______________________________________

 

6.

If applied earlier under SEEUY/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 EDP/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 for arranging land in his own name or/ others to pledge to Bank to erect structures/ dugging well etc. out of Bank finance or taking structures on rent for a long 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 Manager 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 application are true and genuine to be best 

of my knowledge and belief.    

Place :

 

Signature of the Applicant.

 

 

 

Date :

 

 

 

 

 

 

 

 

  (To be torn-out and handed over on demand)

 

ACKNOWLEDGEMENT


Received the application for financial assistance

 under PMRY 2005-06 from

Shri/Smt.……………………………………………………………………………..

Son/Daughter/ Wife of Sri ……………………………………………………………

 Village……………………………… P.O………………………………………….

 P.S. ………………………………………… Dist…………………………………

 along with ……………………………………………….number of enclosed

 sheets today, the ……………………………….

 

 

                                                                                             Signature of the Receiving Officer with Designation.

FORMAT FOR UNDERTAKING

             I ………………………………………………………………………Son/Daughter/Wife of Sri ……………..……………………………………….. 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.40,000/- 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.40,000/- per annum from all sources. (6) That I and my family members have not defaulted in repayment of loan from any Nationalised 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.