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Form No.

_______
PART-II

(To be filled up and submitted to the District Industries Centre after commencement of
production/activity)
[THE ROWS WHICH HAVE BEEN REPEATED NEED TO BE FILLED ONLY TO THE
EXTENT THAT THE ACTUAL DETIALS ON COMMENCEMENT VARY FROM THOSE
IN PART-I]

I. ENTERPRENEURS MEMORANDUM NUMBER (Part-1)

II DATE OF ISSUE D D D M M Y Y Y Y

III. MONTH OF COMMENCEMENT OF M M Y Y Y


PRODUCTION/ACTIVITY

1. NAME OF APPLICANT

2. (a) ADDRESS OF COMMUNICATION

PIN

(i) TELEPHONE NUMBER

(ii) FAX NUMBER

(iii) CELL PHONE NUMBER

(iv) E-MAIL

(v) WEB-SITE

(b) PERMANNENT RESIDENTIAL ADDRESS (MAIN APPICANT)

PIN

(i) TELPHONE NUMBER

(ii) FAX NUMBER

(iii) CELL PHONE NUMBER


(IV) E-MAIL

(V) WEB-SITE

3. NAME OF ENTERPRISE

4. PROPOSED LOCATION OF ENTERPRISE


(i) VILLAGE/TOEN

CODE

(ii) TEHSIL/TALUK/MANDAL

CODE

(iii) DISTRICT

CODE

(iv) STATE

CODE

(v) PIN CODE

(vi) AREA (RURL-1, URBAN-2)

5. CATEGORY OF ENTERPRISE
(MICRO-1, SMALL-2, MEDIUE-3)

6. NATURE OF CTIVITY {Tick Appropriate Box (es?)}


(i) MANUFACTURER

(ii) SERVICE

7. NATURE OF OPERATION
(Perennial-1, Seasonal-2, Casual-3)

8. WHETHER THE UNIT WILL BE AN ANCILLARY


(Yes -1, No-2)
M M Y Y Y Y
9. MONTH OF INSTALLATION OF PLANT
AND MACHINERY
10. WHETHER THE UNIT IS REGISTERED UNDER FACTORY ACT
(Under section 2m(i)/2m(ii)-1,85)I)/85(ii)-2, not registered-3)

11. TYPE OF ORGANIZATION


(PROPRIETARY-1, HINDU UNDIVIDED FAMILY-2, PARTNERSHIP-3, CO-
OPERATIVE-4, PRIVATE LIMITED COMPANY-5, PUBILC LIMITED
COMPANY-6, SELF-HELF GROUP-7, OTHER-8)

12. (a) MAIN MANUFACTURING/SERVICE ACTIVITY

NAME

CODE (NIC98*)

(b) PRODUCTS TO BE MANUFACTURRED/SERVCIE TO BE PROVIDED


(i) NAME

CODE (ASIC2000*)

(ii) NAME

CODE (ASICC2000*)

(iii)NAME

ODE (ASICC2000*)

(iv)NAME

CODE (ASICC2000*)

(v) NAME

CODE (ASICC2000*)

(*) Codes for activities and product/services as per classification specified from time to
time by the Development Commissioner (Small Scale Industries), Government of India to
be filled in by the District Industries Centre or the office where the Entrepreneurs
Memorandum is submitted.
(ADD ADDITIONAL SHEET FOR MORE PRODUCTS)
13. (a) INVESTMENT IN FIXED ASSETS (Rupees in lakh)
(i) LAND (OMNED-01,/RENTED-02, LEASED-03)

VALUE*

(ii) BUILDING (OWNED-01, /RENTED-02, LEASED-03)

VALUE*

(iii) PLANT AND MACHINERY VALUE*


(In case of manufacturing unit)

(iv) EQUIPMENT VALUE*


(In case of service unit)

(v) FOREIGN EQUITY, IF ANY VALUE,*

[* The value in the boxes should be filled in from the right side, e.g. if the value is
Rupees 10 lakhs it should be written as 1 0
This will

also apply to all other items (rows) where quantity, number etc, to be given.]

QTY. UNIT
14. INSTALLED CAPACITY PER ANNUM

15. POWER LOAD H.P. /K.W.

16. (a) (i) OTHER SOURCE OF ENERGY/ POWER


[IF REQUIRED]
(NO POWER NEEDED-1, COAL-2, OIL-3, LIQUID PETROEUM GAS-4,
ELECTRICITY FROM GRID-5, ELECTRICITY FROM GENERATOR-6, NON-
COVENTIONAL ENERGY-7, TRDITIONAL ENERGY/FIREWOOD-8)
(ii) If no power required specify reasons;

(b) INDICATE ANNUAL REQUIREMENT


SOURCE OF ENERGY QTY UNIT
………………………..

………………………..

………………………..

17. EMPLOYMENT MALE FEMALE


(Nos.) (Nos.)

(i) MANAGEMENT AND OFFICE


STAFF

(ii) SUPERVISORY

(iii) WORKERS

18. TOTAL ANNUAL TURNOVER (In Rupees)


(If less than one year of operation, then
Expected turnover)

19. EXPORT (if any) (in Rupees)

17. ENTERPRENEURS’ PROFILE (OF ALL PARTNERS/DIRECTORS OF THE


ORGANISATION-USE SEPARATE SHEETS, IF NEEDED)

(a) NAME

(i) MALE(M) FEMALE(F)

(ii) SC(1)ST(2)OBC(3)OTHERS(4)
PHYSICALLY CHALLENGED (5)

(iii) KNOWLEDGE-LEVEL
(TECHNICAL GRADUATE-1, MANAGEMENT GRADUATE-2,
POST GRADUATE-3, OTHER GRADUATE-4, UNDER GRADUATE-5,
ANY OTHER LOWER-6)

(iv) EQUITY PRTICIPATION


(In Rupees)
(Percentage of total equity)

(v) STAKE IN OTHER MANUFACTURING ENTERPRISES


(Yes-1, No-2)
[ADD ADDITIONAL SHEET IF NEEDED]

18. DATE COMMENCEMENT OF PRODUCTION/ACTIVITY


D D M M Y Y Y Y

DATE:
PALCE:

[SIGNATURE OF THE APPLICAT/AUTHORISED PERSON]


[NAME OF THE PROPRIETOR/PARTNER/MANAGING DIRECTOR]

(a) Enclose a self-certified copy Power of Attorney/Board Resolution/Society


Resolution, wherever applicable, while signing as Partner/Managing Director or
Ahthorised Person.
(b) Enclose a certified/notarized copy of the Partnership Deed/Memorandum of
Association/Articles of Association in case of Medium Enterprises.

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Undertaking

“This is to certify that the information furnished in the memorandum in Form No.
……………… is true and correct to the best of my knowledge and belief. I/We have
obtained approval consent/ license/ permit from the concerned Ministry/ Department of
Central Government/ Sate Government/ UT Administration as per statutory
requirements.”

DATE:
PLACE:

[SIGNATURE OF THE APPLICATION/AUTHORISED PERSON]

_______________________________________________________________________
_

ACKNIWLEDGEMENT

PART-II

M/s…………………………………………………………………………………….HAS FILED
MEMORANDUM FOR A ………………………………… (MANUFACTURKING/SERVICE)
ENTERPRISE AT THE ADDRESS ………………………………………………………………
PIN…………………………….FOR THE ITEM/ITEMS INDICATED BELOW AND THE
ACTIVITY HAS COMMENCE FROM THE (DATE) …………………………………………..
AS STATED IN FORM NO……………………………………….AND ALLOCATED
ENTERPRENEURS’ MEMORANDUM NO. AS BELOW:

DETAILS OF ITEM/ITEMS TO BE MANUFACTURED / SERVICE TO BE PROVIDED

Sr. No. Items of Manufacture / type of service to be rendered Capacity in case of


manufacture
1. ………………………………………………………. ………………………………
2. ………………………………………………………. ………………………………
3. ………………………………………………………. ………………………………
4. ………………………………………………………. ………………………………
5. ………………………………………………………. ………………………………
6. ………………………………………………………. ………………………………
(ADD ADDITIONAL SHEET IF REQUIRED)

NOTE:THE ISSUE OF THIS ACKNOWLEDGEMENT DOES NOT BESTOW ANY LEGAL


RIGHT. THE ENTERPRISE IS REQUIRED TO SEEK REQUISTING
CLEARANCE/ LICENCE/ PERMIT REQUIRED UNDER STATUTORY
OBLIGATION STIPULATED UNDER THE LAWS OF CENTRAL
GOVERNMENT/ STATE GOVERNMENT/ UT ADMINISTRAION COURT
ORDERS:

D D M M Y Y Y Y
DATE OF ISSUE

NATURE OF ACTIVITY

(MANUFACTURING-1, SERIVCES-2)

CATEGORY OF ENTERPRISE
(MICRO-1, SMALL-2, MEDIUM-3)
ENTERPREEURS MEMORANDUM
NUMBER
PART - II
(First two boxes are for State/Union Territory code, next three boxes are for District code sixth
and seventh boxes are for category of enterprise (sixth box for indicting manufacturing or service
and seventh box for indicating micro or small or medium) and last five boxes are for
Entrepreneurs’ Memorandum number)

DATE:
PALCE:

SIGNATURE
WITH OFFICE SEAL

AFFIDAVIT

I_________________________________Son of Sh. _____________________________


Proprietor/Partner/Director of M/s ____________________________________________

________________________________________________________________________

________________________________________________________________________
Do hereby solemnly affirm and declare as under:-

1. That the Industry is covered at Sr. No. ____________ of the list.


2. That the total investment of the industry shall be less than Rs. 10 Lacs on plant &
machinery etc.
3. That the industry is not proposed to be located/is not located in any approved Residential
area Colonies Trust/village Penchayat/any other.
4. That the Industry shall be discharge any air pollution including noise into the at mosphed
5. That there will not be any discharge of trade effluent from the Industry into stream or
well sew or into land due to the establishment or operation on process or any treatment
and disposal an extension or addition thereto.
6. That the Industry will not discharge any toxic/hazardous wastes handle and
toxic/hazardous chemical.
7. That in case the Industry is found to create condition that generate any type of pollution
or there is any abjection from the surrounding community and if on certification, it is
found the such objection has some substance, the Board shall be free to take legal action
under provisions of Water, Prevention & Control of Pollution Act, 1981 as considered
appropriate.
8. That I shall bear all the cost of litigation raised later on by surrounding community etc.

Place : Ludhiana

Dated :

Deponent

VERIFICATION:- Verified that the contents of affidavit from (1) to (8) are
true and correct to the best of my knowledge. No para of it
is false and nothing mate has been kept concealed therein.
Deponent

AFFIDAVIT FOR PERMANENT REGISTRATION


AS
SMALL SCALE INDUSTRIES

I/We_______________________________son/daughter/wife/widow/of_________________
resident of __________________________________________________________________
__________________________________________________________________________
_

do hereby solemnly affirm and declare as under :

1. That I/We have submitted an application dated___________for permanent registration of


the unit as well scale / ancillary / tiny /export oriented unit / small scale service and
business enterprise.
2. That //We am / are proprietor(s) / partner(s) / managing of the unit whose name and
address is given below:-
NAME__________________________________________________________________
ADDRESS______________________________________________________________
_______________________________________________________________________
_
3. That all particulars furnished in the application form are factual and correct.

Contd.2….
4. That the location of the unit does not violate any locational restrictions for the time being
in force and that I/We have obtained the necessary locational clearances from the
competent authority.

5. That I/We have obtained all the statutory clearances/No Objection


Certificates/Permission required to carry out the manufacture/activity under the prevalent
laws, regulations and rules in force.

6. That I/We have also obtained the necessary registration / licence, wherever required,
under the relevant laws, rules or orders, for the time being in force, for carrying out said
industrial activity.

7. That the unit does not require an industrial licence because:-

a) The unit employs less than 50/100 workers with/without power.


b) The items proposed to be manufactured are reserved for exclusive production in the
small scale industries sector.
c) The unit does not manufacture any item which is included in Schedule-II of
Notification No. S.O. 477 (E) Dated 25-07-1991 and is not reserved for exclusive
manufacture in the SSI sector as included in Schedule-III of the above Notification.

8. That the original value of investment in Plant and Machinery installed at the unit is
within the limits prescribed for Tiny/SSI/SSSBE/Ancillary/Export Oriented Unit as per
existing provisions.

9. That the unit is not owned or controlled or is a subsidiary of any other Industrial
Undertaking in terms of the Notification No.S.O.2 (E) Dated 01-01-93.

10. That I/We undertake to inform the registering authority within 30 days of the crossing of
the investment limits in Plant and Machinery and submit the registration certificate for
cancellation of registration or deletion of relevant endorsements as ancillary / EOU / tiny
enterprise / Small scale service and Business Enterprise.
11. That I/We understand that if at a date the said unit does not satisfied any of the conditions
laid down in the Notification No. S.O. 232 (E) Dated 02-04-91 or does not comply with
any of the conditions or restrictions for the time being in force, or includes for
manufacture items that require an industrial licence, then in such an eventuality, I/We
shall be liable and required to surrender our registration as a SSI Unit.

12. That I/We undertake to inform the Directorate of industries/Registering authority


immediately in case a situation arises as mentioned para 11 above.

Contd.3…

13. That I/We undertake to inform and to keep informed the Directorate of Industries /
Registering Authority on all parameters and changes, if any as required from time to
time.

14. That I/We undertake to refund to the Central or State Government any or all financial
incentives or benefits given under various schemes of assistance for Small Scale
Industries along with 18% interest as may be demanded by the appropriate authority of
Central /Sate Govt.,in case it is found that the information or particulars submitted to
obtain registration were wrong and fraudulent.

15. That I/We fully understand that we have to comply with the above conditions failing
which we are liable for action by the Registering Authority for cancellation of the
Registration as well as under other relevant provisions of the laws and rules in force.

Place : Ludhiana
Dated :

Deponent

VERIFICATION:-
Verified that the contents of the affidavit are true to the best of
my knowledge and belief.

Deponent