1. Name of the applicant :
    (in block letters)

2. Sex (male/female) :

3. Father’s/Husband’s name :

          Occupation
          Address

4. Address (self) :
    (a) Permanent
    (b) Correspondence
    (c) Whether residing continuously
    for the last three years in the area
    from where loan is applied                          Yes/No

5. Age Particulars :
    (a) Date of Birth
    (b) Age as on date of application

6. Qualification :
    (a) Academic
    (b) Technical

7. Training received, if any :
    (Give name of the Institute & Duration)

8. Whether the applicant is unemployed? :
    If so, whether registered with
    Employment Exchange?(give
    Registration No. & date)

9. Whether the applicant belongs to :
    SC/ST/OBC

10. Whether the applicant belongs to :
     minority community

11. Type of Industry / service/business :
     activity proposed to be started
     (Give project details)

12. Previous experience in the line, if any:

13. Place of work where the activity as
     mentioned in col. 11 above is
     proposed to be started give full details:

14. Present annual income of the family :
     Duly supported by concerned MRO
     Certificate

15. Amount of loan required
     (a) Machinery & equipment
     (b) Other fixed assets
     (c) Working capital
     (d) Total

16. Margin money proposed to
     be invested by the applicant

17.(a) Whether taken loan from any
     banking/financial/institution or
     state /central govt.
     (b) If yes for 17(a) whether all&
     repayments made
     (c) If No for 17(a) indicate the
     balance amount.

18. I certify that all information furnished by me is true, and that I have no borrowing
      arrangements for my above proposed industrial service/business concern with any
      bank/financial institution.

Signature of the applicant