Annexure - 1: Application Form

Part-I

1. Name of the Unit

2. Address:

Office:

Factory:

Tele No. :

Fax No. :

Email:

3. Constitution of the Unit Proprietorship/ partnership/ company/ society/ others

4. Name, address & contact details of the Promoter

5. Name, designation & contact details of the Authorize Person

6. EM No. & Date (MSMEDA Part-II)

7. Details of any other financial assistance granted by GOG/GOI

8. Whether any Government dues are outstanding or not? If Yes Give details thereof

9. Whether any court case? If Yes Give details thereof

10. Declaration:

I hereby declare that the information, statements & other papers given herein are to the best of my knowledge & belief, true and correct in all particulars, incentive government resolutions and prevailing government rules and regulations.

I also declare that I am duly authorized to sign an application and details and documents submitted in this application.

Note: Any financial transactions / expenditure statements submitted by the unit must be signed by the authorized signatory of the institute and certified by the auditor/ chartered accountant, if applicable

Date: Signature of Authorized Signatory Place: Seal of the Unit

Annexure - 1: Application Form

Part-II: Scheme for Quality Certification

1. Name of the Unit

2. Plant Details:

Manufacturing Item :

Annual production Capacity:

Investment in Plant & Machinery:

3. Name and address of certification agency and the certificate No. & its date and the details for which the certificate has been obtained

4. Details of cost incurred, along with CA certified statement

Sr. Purpose Party’s

Name Invoice No.& date

Invoice Amount

Receipt No. date &

Amount

Remarks

1 Application fee/ certification fee

2 Assessment/ Audit Fee 3 Annual fee/ License fee 4 Pre-Certification

Expenses

5 Consultancy/Training/ Calibration charges, etc. (show the details of each separately)

7 Cost of testing equipments as suggested by BIS

6 Miscellaneous expenses, if any

Total

5. Other information, if any

6. I hereby opt for Quality Certification assistance under the scheme of (Mark tick as appropriate)

Scheme under Industrial Policy, 2003 as a pipeline case @ □

Scheme under Industrial Policy, 2009 □

7. Declaration: I here by affirm and declare that the information furnished in this

form is authentic and correct to best of my knowledge. I am authorized to sign and submit this application.

Date: Signature of Authorized Signatory Place: Seal of the Unit @ The Industrial Unit which made expenditure prior to 26.02.2009 and obtained quality certificate on or before 26.02.2010 will be eligible under the Scheme.