Application No.

Please give the information on a separate sheet

duly signed, if the space provided is not sufficient.

1) Name of the applicant / :

Industrial unit.

b) Factory Address and telephone :

number.

i) Village :

ii) Post Office :

iii) Taluka & District :

iv) Plot No. :

Full particulars about the other Divisions / Branches :

/ Depots in India.

2) Constitution and date of Establishment of :

the applicant Unit.

3. Name and full postal residential address/es :

of Directors

4) Products for which registration obtained. :

5) Whether the unit is 100% EOU, BHTP, :

Agro-Industry or Electronic Industry unit .

6. a) Details ( with date of previous applications, :

if any, filed for eligibility either under the

1993 Scheme for under the earlier Scheme

of Incentives ( if no application is at all filed,

it should be so mentioned).

Date of application :

Date of filing :

Scheme : (1969 / 1973 / 1976 / 1979 / 1983 / 1988/1993). :

a letter of Intent under the

earlier scheme, indicate No. &

Date.

Letter of Intent No. :

Date :

Scheme : ( 1969 / 1973 / 1975 /

1979 / 1983 / 1988 / 1993 ).

7) Cost of the Project : (Rs. In lacs)

a) Land :

b) Building :

c) Plant & Machinery :

d) Technical know-how fees / :

e) Other Assets ( specify in brief):

f) Preliminary expenses :

g) Pre-operative expenses :

f) Provisions for contingencies :

i) Margin for Working Capital:

8) Date on which effective steps are :

taken / completed.

( If any of these are not taken /

completed, please indicate clearly )

I.

i) Possession of land :

1. Permission for non agricultural use or zoning :

certificate, if the location is outside the MIDC

area.

2. State / Central Government Registration or :

ration / Maharashtra Pollution Control Board /

A)

a) Registration Authority : District Industries Centre,

b) Date of Registration :

c) Registration / License No. :

d) Items for which registered :

B)

b) Date of consent to establish :

c) Consent to establish No. :

d) Items for which consented :

II.

iv) C. G. Clearance / Import license :

v) FERA / MRTP Clearance :

vi) Means of Finance :

( Rs. In lacs )

a) Share Capital – Equity :

b) Term Loans ( Bank / financial Institution.) :

c) Foreign Currency Loan :

d) Debentures / DPG :

e) Internal Cash Accruals :

f) Other ( Unsecured Loans) :

1. Acquisition up to 10% of fixed Assets of the :

Project Cost at site.

2. Project expenditure incurred up to 25% of :

9) Date of expected date of commencement :

10) Registration under the Sales Tax Act. :

1. Registration under the Bombay Sales Tax :

( Detail in respect of all :

Registration to be furnished )

Registration No. :

Date :

Date of Effect :

ii) Registration under the Central :

Sales Tax Act, 1956

Registration No. :

Date :

Date of Effect :

( Additional Place )

Registration No. :

Date :

Date of Effect :

iv) Whether Registration obtained as a new unit :

or a transferee / shifting.

1. Whether permission to file consolidated :

number and date.)

11) Accounting year followed / Proposed :

to be followed by the applicant.

12) Average number of workers : Local Total

proposed to be employed.

Supervisory : a) Technical :

13) Estimated Electric power requirement in K. W. :

14) Source of water supply / water requirement. :

(1) Certified that no letter of intent or Eligibility / Certified for any of the project / s / unit / s aforesaid has been granted except as mentioned in column No. 5 and that this is the first application in regard to the project / unit aforesaid.

(2) Certified that the information / statement contained in this application for Eligibility Certificate are true to the best of my / our knowledge and belief.

(3) Declared that no Government enquiry has been instituted against the applicant and / or its proprietor / partners / directors for any economic offence.

We hereby agree to abide by the terms and conditions of the letter of intent / Eligibility Certificate to be issued in pursuance of the above application for Eligibility Certificate.

I / We hereby agree that the letter of intents / Eligibility Certificate / Certificate of Entitlement issued on the basis of the above statements made and information furnished either along with this application or hereafter in connection with the above matter is liable to be cancelled ab-intio or rendered invalid or withdrawn, if any of the statements and / or information is / are found to be incorrect / untrue. All the monetary benefits already availed of or the basis of the Eligibility Certificate so cancelled shall be recoverable as Government dues forthwith along with compound interest @ 22% per annum or at such other higher rate as may be fixed by the Implementing Agency from time to time and no further benefits will be available to the project / unit for which the above application is made.