APPLICATION FORM FOR STATE EMPLOYMENT SCHEME 1. Name of the applicant(in block letters):-Space for 2. Sex (Male/Female):- photograph 3. Particulars of Father/Husband i. Name: j. Permanent address (Where residing for the last more than three years 4. Particulars of applicant:a) Permanent Address: b) Village/Mohalla: c) Post Office: d) District: e) Address for corresponding: f) Date of Birth: g) Academic and technical qualification S.No Examination Year of Divisio Name of Passed Passing n University/Board h) Experience in the trade selected for self-employment. i) Specific training received(give details of training, duration, name of institution) j) What have you been doing after passing the last examination. a) Service Govt./Govt. Undertaking Yes/No. b) Business/ Agriculture Yes/No. c) Self-employment Yes/No. d) Service in Private Establishment Yes/No. k) Present employment status Employed/Unemployed. l) Whether registered with Employment Exchange. m) Whether a member of Scheduled Cast/Scheduled Tribe/OBC(please specify) 5. Type of Activity proposed to be undertake: 6. Previous experience: 7. Place where the activity is to be undertaken: 8. Whether Premises available Yes/No. i) If Yes, State the specific arrangement made as under: a) Rented: b) Owned: 9. Whether construction of premises is a part of the project Yes/No. 10. Project Cost a. Machinery : b. Buildings: c. Other fixed assets: d. Working Capital: e. Total : 11. Amount of Loan at 75% of the project cost: 12. Whether loan taking from any bank or financial institution so far Yes/No. i. If yes state the purpose. ii. Repayment position with regard to outstanding, default, etc. UNDERTAKING BY THE APPLICANT I certify that the information furnished by me is correct and I have not so far made any agreements for financing the project with any financial institution. Signature of the Applicant. (FOR OFFICE USE ONLY) Serial No: Selection No: Block: Constituency: CERTIFICATE ABOUT UNEMPLOYMENT OF THE CANDIDATE TO BE ISSUED BY A GAZETTED OFFICER. Certified that Mr./Miss/Mrs.:-...................Son, Daughter, Wife of :......................... Resident of.........................is not an employed in Govt./Undertaking. Further certified that he/she is not working in any private establishment nor does he/she carry on any business in his/her name. He/she is not student of any institution. Sig. Of the Gazetted Officer, Name Designation Official Seal. IDENTIFICATION CERTIFICATE FROM A GAZETTED OFFICER I certify that Mr./Miss/Mrs: .......Son, Daughter, Wife of:-Resident of :-..................Whose photograph has been attested by s me and who has put his/her signature in my presence is personally known to me. Sig. Of the Gazetted Officer. Paste recent passport size Name:-Photograph duly attested Designation:- By a Gazetted Officer. Official Seal.
