GOVERNMENT OF _________________
DIRECTORATE OF INDUSTRIES
APPLICATION FORM FOR PROVISIONAL REGISTRATION AS
SMALL SCALE INDUSTRIES
(TO BE FILLED IN DUPLICATE)

INSTRUCTIONS

  1. Write/type in block (capital) letters.
  2. Fill up whichever is applicable.
  3. Use English alphabets/Arabic numbers while filling up blocks (to help computerisation). Leave one blank after each word.
  4. While filling the form, use the following procedure.
i) Name of the unit e.g. KAMAL ENTERPRISES/G.K ENTERPRISES
 
K A M A L   E N T E R P R I S E S      
G   K   E N T E R P R I S E S          
ii) Pin Code: e.g. 110041 1 1 0 0 4 1
iii) Date: e.g. 23rd June 1959 2 3 0 6 5 9
iv) Quantity (kg) e.g. 90 Kg. 0 0 0 0 9 0
v) Amount (Rs in thousands) e.g. Rs. 5000/-   0 0 0 0 5

vi) Fill up appropriate codes in the blocks wherever applicable
 
  Example 1: Yes-1, No-2, NA-3           3

if NA fill up-3
Example 2: Category: SSI-1, Anc-2,
Tiny-3, SSSBE-4,

EOU-5.           3

If Tiny fill up-3 5. Block/boxes marked (*) are to be filled by office.

6. Applicant should sign all copies.

Abbreviations used:

SSI : Small Scale Industries, ANC : Ancillary Industrial Undertaking, SSSBE : Small Scale Service and business enterprise, TINY : Tiny enterprise, EOU : Export Oriented Unit, NA : Not applicable.

FORM
  1. Name of the Unit/Applicant.
                                       
                                       

2. Address for communication.
 
                                                           
                                                           
                                                           
Tel:                     Pin Code:                      
3.     Category of Unit  

SSI-1, ANC-2, SSSBE-3,
TINY-4, EOU-5.

4. Location:
 
Place/Town                                      
Tehsil/Taluk                                      
District                                      
State                                      

5. Type of Organisation:

Proprietary-1, Partnership-2, Pvt. Company-3, Cooperative-4,
 
Others                                      

6. Nature of activity
 
Manufacturing/Assembly (01)    

Processing (02)

Job work (04)

Repairing/Servicing (08)

Note: For any combination of activities, add the respective code to get the required code.

7. Main items of manufacture/activities.
 
i) Name                                                
Code                                                
ii) Name                                                
Code                                                
iii) Name                                                
Code                                                
iv) Name                                                
Code                                                
v) Name                                                
Code                                                

8. Investment in Fixed Assets (Rs. in 000)
 
i) Land                                                
ii) Building                                                
iii) Plant & Machinery                                      
iv) Other Fixed Assets                                      
TOTAL:                                                

9. Investment in Plant & Machinery
 
(original value Rs. in 000)                          

Note: Should exclude items whose value is not taken into account while computing the investment. Please enclose project profile in case value of investment in Plant and Machinery exceeds Rs.40 lacs.
 
10. Power Load H.P.                      
(1 H.P. = 0.795 K.W) K.W.                      

11. Employment
 
i) Management & Office Staff                      
ii) Supervisory and Workers                      
12. Date of commencement of production                  

(estimated)
 
Date:                                                

Signature of Applicant (Authorised Person)

Name of proprietor/partner/managing director

FOR OFFICE USE ONLY


 
Application No.             NIC Code        
Block Code       District Code         State Code        
Location of Unit                  

(Conforming-1, Non-Conforming-2)

Whether the items of manufacture/activity require an industrial licence.
 
Yes-1, No-2  

(No industrial licence is required for items listed in Schedule II of the licensing notification dated 25.7.1991 if the unit employs less than 50/100 workers with/ without power)