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Annexture -I
Society for Self Employment of
Unemployed Youth, West Bengal
Y}Y O>[ }Y Hm (YYY)
Bangla Swanirbhar KarmasanasthanPrakalpa (ATMAMARYADA)
Y| APPLICATION FORM
I Y| YZ [ ]
I Particulars of the applicant ]
1l Y
1. Name (In Capital letter) ]
2l [ Y /O>YZ Y ]
2. Father's / Husband's Name ]
3l ( ) _YZ [ YY (| [| Y } ) ]
3. (a) Full permanent address with
Telephone No. if any (In capital letter)
]
() Y _[ YY (| [| Y } ) ]
(b) Present full address with Telephone
No. if any (In capital letter)
]
4l fG Y[ ( \[ Y [| |) ]
4. Date of Birth (attested copy of supportingdocuments)
]
5l [ Y {Y\ Y ( \[ Y [| |) ]
5. Educational qualification (attested copy ofsupporting
documents)
]
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6l }Y { | [^[q E> ( \[ [| |)
]
6. Employment exchange Regn. No. (attested
copy)]
7l [Z Y[ /Y[ / [ WZ ( \[Y [| |)
]
7. SC / ST / PHE (attested copy of supporting
documents)]
8l ( ) Y[Y[ {Y ]
8. (a) Family occupation ]
() Y[Y[ Y[ Y ( \[ Y
[| |)
]
(b) Monthly family income (attested copy of
supporting documents)]
II Hm[ ]
II Scheme / Project details ]
9l \Y Y ] (^ |\Y/^Z[ / [ |\Y)]
9. Business status : (New / Revival / Running) ]
10l Y[ |Hm }[ [( |Hm Y \Y[)([ Y[ [ YYY Y| [| |)
]
10. Short description of the proposed scheme
(Name of the scheme etc.)
(details to be furnished in separate sheet)
]
11l ( ) |Hm {Y ]
11. (a) Total project cost ]
() \Y& | [Y ]
(b) Bank loan component ]
() \Y { | Y [ YY, { [| Y } ( [ |\Y| { |)
(c) Present address with Telephone No. if anyof business place :
(In case of running business)
]
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12l Y[ |Hm _[ YY ]
12. Full location address of the project ]
13l Hm[ _Y[ | [O>/ YY Y YY([ Y[ [ [| |)
]
13. Project to be located on own, hired /lease land etc.
(details to be furnished)
]
III \Y\ [ ]
(III) Other details ]
14l ( ) _|{ Y |Hm YZ {|| [ Y ]
14. (a) Whether received any loan previouslyunder Govt.
sponsored programme
]
() [ {| Y| , YZ | [Y ]
(b) If yes, then amount of subsidy received ]
() [|Y || [ Y ( \YY[ }|Y[ | |)
]
(c) State whether loan with interest has beenfully repaid
(necessary documents to befurnished in support or repayment)
]
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YYUndertaking
YY e Y [L>Y | | [`[ [ \. Y[ Z / Z Z
llllllllllllllllllllllllllllllllllllllllllllllll
llllllllllllllllllllllllllllllll | &Z Y [T {, }Y { | YY Y
[^q | Y
(Exchange Card) Hm[ _Y| \ ^|Y | Y[ Y| [ YY | } ^_ [|Y| Y[ [ YY
[Y \YY | {Y |. [ Y| |\Y[ { Y }Y| \ }Y { Y Y YY [ YZ Y.
The above statement is true to the best of my knowledge and
belief. I, Shri / Smt.
........................................................do
hereby undertake that the Employment Exchange Card will be
kept in abeyance in the event of sanction of loan for execution
of the scheme and that the abeyance
will be lifted only after the loan with interest has been repaid
in full. During the period of abeyanceof the cards I shall not be
entitled for any employment call from the Employment Exchange.
Y[ _ Y[, Y| YZ { Y \YZ \.
llllllllllllllllllllllllllllllllllllllllllllllllllllll(Y| YZ
O>Y )
(Full signature of the applicant)To the best of my knowledge
the
information furnished by the
applicant is true.
.........................................................
.........................................................
.........................................................
( Y| D_Y } O> Y ) (|a / {Y|Y ^ Y[ Y[| O>Y )
(Name & signature in full of the
Motivator)
(Signature of the M. Y. O. / Br. Y. O.)
( Hm_Y [[ \)(Remarks of the project
implementation committee)
