PROFORMA APPLICATION FOR DISBURSEMENT OF CONNECTIVITY SUBSIDY FOR INFORMATION TECHNOLOGY INDUSTRIAL UNITS 1 Name of the applicant 2 Address for communication Phone Fax e-mail 3 Name & address of the Industry Phone Fax e-mail 4 Whether sole proprietorship/ Partnership/ Pvt. Ltd./ Public Ltd. 5 Name of the products manufactured (Approved) 6 Date of commencement of production (copy of SSI PMT registration certificate to be enclosed) 7 Whether the unit is registered with STPI (if yes furnish details) 8 Type of connectivity 9 Agency / Authority from whom connectivity is obtained 10 Connectivity lease charges paid per annum (Original bills and receipts to be enclosed) 11 Period for which the subsidy is claimed Period Amount (Rs) AFFIDAVIT The particulars furnished above are true and I hereby undertake to refund the entire subsidy with interest if any false claim is found subsequently. Signature of the applicant Place: Date:
