GOVERNMENT OF TRIPURA Sl. No. DEPARTMENT OF INDUSTRIES & COMMERCE Application Form for financial Assistance under Prime Minister's Rojgar Yojana for Educated unemployed Youth For the Year 2002 - 2003 1. Name of the applicant : Shri/Smt./Kumari ................... ( in block letters ) ................... 2. (i) Name of Father/Husband ................... (ii) Occupation ................... (iii) Full Address P.O........ Vill........ Telephone no.......... 3. (i) Full Address of the applicant : (a) Permanent P.S..........Dist...... (b) Present Gaon Sabha............... (ii) Present Occupation Municipality Word No.......... (iii) Whether residing continously for Yes/No the last three years in the area from where Loan is applied. 4. (i) Date of birth of the applicant. .................... (ii) Age as on date of application, ...years...month...days.... 5. Qualification : (i) Academic. ................... (ii) Technical. ................... 6. Training received, if any (give name ...................... of institute & duration) 7. Whether the applicant is unemployed? ..................... If so, whether registered with employment Exchange (Give registration No. & Date ) 8. Whether the applicant belongs to SC/St/OBC .................... If yes, please indicate. 9. Type of industry/service/business activity .................... Proposed to be started (project details to Be enclosed). 10. Previous experience in the line. If any .................... 11. Proposed place of activity .................... 12. Present annual income of the family duly supported by the Revenue officer attached to Office of S.D.O. Rs. ................... 13. Amount of loan required (as per project) : Rs.................... (a) Machinery & Equipment Rs. ................... (b) Other fixed assets Rs. ................... (c) Working capital Rs. ................... Total:- Rs. ................... 14. Margin money proposed to be invested Rs. ................... 15. (a) Whether taken loan from any banking/ Financial institution of State/Central Govt. (b) If yes, whether all repayments made (c) if no, indicate the balance amount Rs. .................. 16. I certify that all information furnished by me is true and that I have no borrowing aggrements for my above proposed industrial/service/business concern with any Bank/Financial Institution. Date of submission Signature of the applicant 17. Report of the Enquiry officer. Signature of the Enquiry Officer. Full Name :- Designation :- 18. Observation of the General Manager. Signature of the General Manager. 19. Specimen copy of affidavit to be submitted along with the application on Non-Judicial paper duly attested by 1st class Judicial AFFIDAVIT ................S/O/D/O/W/O.................. ....................R/O..........Dist........ .............State........... (i) that I am unemployed. (ii) That I am not in a position to muster my own capital for the project. (iii) That I am a permanent resident of ..........since.......... Years......... (iv) that the family income of my family which includes spouse and parents isRs.... per annum from all sources such as salary, wage, agricultural income, business rent, interest, pension etc. (v) that I have not defaulted inrepayment of loan from any nationalised Bank/Financial Institutions/Co-op. bank (vi) that I shall abide by the rules framed under the Scheme of 'Prime Ministers Rozgar Yojana (PMRY) for Educated Unemployed Youth. (vii) that I shall submit the progress report required by the Bank's/Govt. 20. VERIFICATION :- Verified that the above content are true and correct to the best to my knowledge and belief and nothing has been concealed therein. DEPONENT CHECK LIST FOR APPLICATION UNDER PMRY ESSENTIAL ELIGIBILITY CRITERIA 1. Whether combined income of the family (including beneficiaries/spouse) is up to Rs. 40,000/- P.A Yes/No 2. Is the name of applicant concerned included in the family ration card. (PRC issued by SDO's Office in support of residency) Yes/No 3. Whether the applicant has been residing in the area mentioned, continuously for the past three years (PRC issued by SDO to be furnished) Yes/No 4. Whether the age of applicant is between 18 & 40 years (15 year relaxation for SC/ST/Women/Ex-Servicemen/Physically handicapped) Yes/No 5. Educational qualification of the applicant :- (i) Matric passed/Failed/Class VIII Passed Yes/No (ii) ITI Certificate Passed Yes/No (iii) Technical Training Course of Govt. Yes/No 6. Whether the applicant is registered with Employment Exchange Yes/No 7. Whether the applicant has any debt or recovery pending from a Yes/No Bank/Financial Institution OTHER ELIGIBILITY CRITERIA 8. Whether the application is complete/has necessary details Yes/No 9. Whether the project cost is within the PMRY Scheme limits of Rs. 1.00 lakhs for business and Rs. 2.00 lakhs for industry and service per individual Yes/No 10. Whether the applicant is ready to contribute 5 % margin as beneficiary contribution as per Scheme Yes/No 11. Whether the applicant is ready to under-go training after sanction of loan Yes/No CRITERIA FOR PREFERENCE 12. Whether the applicant belongs to ST/SC/OBC Community or is he Ex-serviceman/ Physically Handicapped/Women. Yes/No 13. Whether the applicant is qualified for selection on priority in view of experience/skill in the scheme applied for Yes/No OTHER INFORMATION 14. The nature of site/address of the activity applied Own/Hired 15. The type of activity :- i. Industry ...................... ii. Service ...................... iii. Business ...................... iv. Others (Please Specify) ...................... LIST OF DOCUMENTS TO BE ENCLOSED i. Age Certificate. ii. Certificate of Qualifications-academic and technical. iii. Ration Card or any other proof of residency for 3 years. iv. Experience Certificate if applicable v. Copy of the Project Profile out line. vi. Copy of Employment exchange Registration cad. vii. Certificate regarding ST/SC/OBC/Ex-Serviceman/P.H. viii. Copy of Citizenship Certificate ix. Copy of Passport Size Photo duly attested . x. Income Certificate from Competent authority. xi. Permanent resident Certificate from Compenent authority
