APPLICATION FOR EXEMPTION FROM PAYING EARNEST MONEY DEPOSIT/ SECURITY DEPOSIT BY SMALL SCALE INDUSTRIAL UNIT 1. Name of the unit (Block Letters) : 2. Address with Telephone No. if any : 3. SSI Registration No.& Date : 4. Type of Management : 5. Name and address of the Proprietory/Managing partner/ Chief Executive with Telephone No. if any : 6. Whether the applicant belong to SC/ST (Give Details) : 7. Name and Address of the Contracting Firm/ Department : 8. No. and date of tender / contract : 9. Items to be supplied : 10. Amount of contract : 11. Amount of EMD/ Security to be furnished : 12. Period of contract : 13. No. date of EMD /security deposit, certificates previously received from the Department : 14. Details of previous contracts entered into by the unit and date of completion. (Department No. & date of contract items supplied, amount etc.) : 15. Details of machinery installed : Sl. No. Name of Machinery Maker's Name& Productive Value Specification capacity (8) Hours 16. Items manufactured/ Job work/ servicing repairing/ processing : 17. Total investment : a) Land & Building : b) Machinery : c) Others : 18. Name of Bankers and Account No. of the unit : 19. If workers employed : 20. Whether the following registers are maintained : 1. Raw material register : 2. Finished product register : 3. Attendance Register : 4. Sales tax registration and sales tax payments : 5. Register for yearly return : 6. Bill Books : 21. Whether the unit it disqualified debarred/ punished for non compliance of contractual obligations or any enquiry on such matters pending : 22. Remarks: Supervisory : Skilled : Unskilled : Others : Total : (If any other particulars the unit intends to communicate may be entered here) C E R T I F I C A T E I declare that the above statements are true to facts and comparative with the records and registers maintained. Place: Signature of thee Applicant Date: Name and Designation Enclosures 1. Balance sheet/ Annual statement for previous 2 years : 2. Copy of tender / contract : 3. Copy on PMT Certificate(SSI) : 4. 5. For office use only
