Classication for the companies will be as per the Government of India’s denition which is based on the investment in the plant and machinery for manufacturing and in the equipment for enterprises providing or rendering the services.

·¤�ÂçÙØæð´ ·¤æ ß»èü·¤ÚU�æ ÖæÚUÌ âÚU·¤æÚU ·¤è ÂçÚUÖæáæ ·ð¤ ¥ÙéâæÚU ç·¤Øæ ÁæØð»æ, Áæð ç·¤ ©U�ÂæÎÙ �æð�æ ×ð´ �Üæ�ÅU °ß¢ ×àæèÙÚUè ×ð´ ·é¤Ü çÙßðàæ ÌÍæ âðßæ �æð�æ ×ð´©U·¤ÚU�ææð´ ×ð´ ç·¤Øð »Øð ·é¤Ü çÙßðàæ ÂÚU ¥æ�ææçÚUÌ ãñÐ

1. Is your company registered with Ministry of Micro, Small & Medium Enterprises, Government of India?

(�Øæ ¥æ·¤è ·¤�ÂÙè âé�×, Ü�æê °ß¢ ×�Ø× ©Ulæð» ×¢�ææÜØ, ÖæÚUÌ âÚU·¤æÚU mUæÚUæ ÚUçÁSÅUÇüU ãñU?) YES(ãUæ¢) NO(ÙãUè´)

If yes, which category do you fail under? (ØçÎ ãUæ¡, Ìæð ¥æ 緤âæ �æð�æè ×ð´ ¥æÌð ãñ´¢?)

Micro (âé�×) Small (Ü�æé ) Medium (×�Ø× )

SSI Registration/EM Part-2 No. (°â.°â.¥æ§ü. ÚUçÁSÅðUþàæÙ / §ü.°×. ÂæÅüU-2 Ù�ÕÚU) _____________________________________________ Date(çÎÙ梷¤) _______________Note: The SSI Registration/EM number is compulsory for the registered MSMEs (ÚUçÁSÅUÇüU °×.°â.°×.§ü. ·ð¤ çÜ° °â.°â.¥æ§ü. ÚUçÁSÅðUþàæÙ/§ü.°×. Ù�ÕÚU ÂýÎæÙ ·¤ÚUÙæ ¥çÙßæØü ãñU)

Ownership Pattern (Sßæç×�ß ·¤æ Âý·¤æÚU)

Proprietary (Sßæ×è) Partnership (âæÛæðÎæÚUè) Private Limited (Âýæ§ßðÅU çÜç×ÅðUÇU) Public Limited (Âç�Ü·¤ çÜç×ÅðUÇU)

Are you a 100% EOU? (�Øæ ¥æ 100 ÂýçÌàæÌ §ü.¥æð.Øê. ãUñ?) Yes No

Total Number of employee (including contract labour) (·¤×ü¿æçÚUØæð´ ·¤è ·é¤Ü â¢�Øæ (·¤æò�ÅUþð�ÅU ÜðÕÚU âçãUÌ))Male (ÂéM¤á) Female (×çãUÜæ)

Proprietors / Partners / Promoters (àæèáü ÂýÕ¢�æÙ)

1. _____________________________________________________ Designation (ÂÎ): __________________________________ Age (¥æØé): ________

2. _____________________________________________________ Designation (ÂÎ): __________________________________ Age (¥æØé): ________

3. Operational Details

Please select ONE INDUSTRY from the following 13 sectors, you would like to be nominated under for the awards:

Application Information Form

Auto Components (¥æòÅUæð ·¤�ÂæðÙð´Å÷Uâ)

Engineering Goods (including machinery Electrical & Electronic Goods & Components (§¢ÁèçÙØçÚ¢U» âæ×æÙ (×àæèÙÚUè, §Üðç�ÅþU·¤Ü, §Üð�ÅþUæðçÙ�â ©U�ÂæÎ ß ©U·¤ÚU�ææð´ âçãUÌ))

Food & Agro Products (¹æl÷Ø °ß¢ ·ë¤çá ©U�ÂæÎ)

Handicrafts and Wooden Furniture (ãñU�ÇUè·ý¤æ�Å÷U⠰ߢ Ü·¤ÇUè ȤÙèü¿ÚU)

Textile (including readymade garments) (ÅñU�âÅUæ§Ëâ (ÚÔUçÇU×ðÇU ßS�ææð´ âçãUÌ))

IT & ITES (except Hardware) (¥æ§üÅUè-¥æ§üÅUè§ü°â (ãUæÇüUßðØÚU ·ð¤ ¥çÌçÚUQ¤))

Paper & Packaging (ÂðÂÚU °ß¢ Âñ·ð¤çÁ¢»)

2. Company Information (·¤�ÂÙè ·¤æ çßßÚU�æ )

Name of the Company (·¤�ÂÙè ·¤æ Ùæ×) Year of Establishment

(SÍæÂÙæ ßáü)

Registered Address (¢Áè·ë¤Ì ÂÌæ)

Telephone (ȤæðÙ Ù�ÕÚU) FAX (Èñ¤�â)

Website (ßðÕâæ§ÅU) Email (§ü-×ðÜ)

Page 1 / 4

MSME AWARD 2015, HARYANA

Apparel, Fashion Garment & Accessories (ÂçÚU�ææÙ, Èñ¤àæÙ ÂçÚU�ææÙ °ß¢ âãUæØ·¤ °âðâÚUèÊæ)

Scientic, Measuring & Laboratory Instruments (ßñ�ææçÙ·¤, ×æÂÙð °ß¢ ÂýØæð»àææÜæ ·ð¤ ©U·¤ÚU�æ)Metal and Metal Products (ÜæðãUæ °ß¢ ÜæðãUæ ©U�ÂæÎ)

Major Products

Page 2 / 4

Total no. of Plants (Manufacturing Sector) OR delivery centers (IT-ITeS) OR Hotel / Resorts

Location of Plants (Manufacturing/delivery centres (IT-ITeS) / no. of Rooms (Hotel/Resorts)

Total Installed capacity of all plants and units of measurement P.A./no. of seats (IT-ITeS) /no. of rooms (Hotels/Resorts)

Investment in plant & machinery/equipment (excluding land & building)

a) Manufacturing Upto T25 lakh More than T25 lakh & Upto T5 crore More than T5 crore & upto T10 crore

(T25 Üæ¹ Ì·¤) (T25 Üæ¹ âð ¥ç�æ·¤ °ß¢ T5 ·¤ÚUæðÇU¸ Ì·¤) (T5 ·¤ÚUæðÇU¸ âð ¥ç�æ·¤ °ß¢ T10 ·¤ÚUæðÇU¸ Ì·¤)

b) Service Sector Upto T10 lakh More than T10 lakh & Upto T2 crore More than T2 crore & upto T5 crore

(T10 Üæ¹ Ì·¤) (T10 Üæ¹ âð ¥ç�æ·¤ °ß¢ T2 ·¤ÚUæðÇU¸ Ì·¤) (T2 ·¤ÚUæðÇU¸ âð ¥ç�æ·¤ °ß¢ T5 ·¤ÚUæðÇU¸ Ì·¤)

4. Financial Details (Information will be strictly used for analytical purpose and kept strictly condential)

Note: Kindly only provide the audited gures for FY09-10 and FY10-11 (ÙæðÅUÑ çßç�æØ ßáü 09-10 °ß¢ 10-11 ·ð¤ ·ð¤ßÜ ¥¢·ð¤ç�æÌ ¥æ¢·¤Çð¸U ©UÂÜ��æ ·¤ÚUæ°¢)

Please specify the top ve-exporting countries with (·ë¤ÂØæ çÙØæüÌ ·¤ÚUÙð ßæÜð Â梿 àæèáü Îðàææð´ ·¤æð ©UËÜðç¹Ì ·¤ÚÔU)

5. Miscellaneous (¥�Ø/çßçß�æ)

Do you have a credit rating report? If yes, kindly mention the agency (�Øæ ¥æ·¤ð¤ Âæâ ·ðý¤çÇUÅU ÚÔUçÅ¢U» çÚUÂæÅüU ãñU?) ØçÎ ãUæ¡ Ìæð ·ë¤ÂØæ °Áð´âè ·¤æ ©UËÜð¹ ·¤ÚÔ´U

Haryana MSMEs are competitive in Global Market? (ãUçÚUØæ�ææ ·ð¤ °×.°â.°×.§ü. ßñçàß·¤ SÌÚU ÂÚU ÂýçÌSÂhUè ãñU?) YES (ãUæ¡) NO (ÙãUè´)

Benets derived by the company from the State : (Kindly rate them in the order of 1 to 8 with 1 being the highest and 8 being lowest)(ÂýÎðàæ âð ·¤�ÂÙè ·¤æð ç×Üð ÜæÖ (·ë¤ÂØæ §�ãð´U °·¤ âð ¥æÆU Ì·¤ ·ý¤× ×ð´ ßÚUèØÌæ Îð´, çÁâ×ð´ °·¤ ¥ç�æ·¤Ì× °ß¢ ¥æÆU �ØÙÌ× ßçÚUØÌæ / S·¤æðÚU ãñU))

·é¤Ü âØ¢�æ (çßçÙ×æü�æ �æð�æ) Øæ çÇUÜèßÚUè âð´ÅUâü(¥æ§üÅUè-¥æ§üÅUè§ü°â) Øæ ãUæðÅUÜ/çÚUâæðÅ÷Uüâ

âØ¢�æ (çßçÙ×æü�æ �æð�æ) Øæ çÇUÜèßÚUè âð´ÅUâü (¥æ§üÅUè-¥æ§üÅUè§ü°â) Øæ ãUæðÅUÜ/çÚUâæðÅ÷Uüâ ·¤æ ÂÌæ

âÖè âØ¢�ææð´ ·¤è ·é¤Ü SÍæçÂÌ �æ×Ìæ °ß¢ ×æ ·¤è §ü·¤æ§üØæ¢, Âè.°.âèÅUæð´ ·¤è â¢�Øæ(¥æ§üÅUè-¥æ§üÅUè§ü°â) Øæ ·¤×ÚUæð´ ·¤è â¢�Øæ (ãUæðÅUÜ/çÚUâæðÅ÷Uüâ)

Benets (ÜæÖ) Rank (Úñ´U·¤)

Government support for entrepreneurship

Raw material procurement

Better infrastructure

Technology up-gradation

(©Ulç×Øæð´ ·ð¤ çÜ° âÚU·¤æÚUè âãUæØÌæ)

(·¤�¿ð ×æÜ ·¤è ¹ÚUèÎ)

(ÕðãUÌÚU ÕéçÙØæÎè âéçß�ææ°¢)

(Ì·¤Ùè·¤è ©U�ÙØÙ)

Benets (ÜæÖ) Rank (Úñ´U·¤)

Obtaining Finance

Skilled Manpower

Export Promotion Measures

Others, please specify

(çß�Ì Âýæ�Ì ·¤ÚUÙæ)

(·é¤àæÜ ×ñÙÂæòßÚU)

(çÙØæüÌ â¢ß�æüÙ ·ð¤ ©UÂæØ)

(ØçÎ ¥�Ø, Ìæð ·ë¤ÂØæ ©UËÜð¹ ·¤ÚÔ´U)

Financial Details (Tcrore) çßç�æØ çßßÚU�æ - ·¤ÚUæðÇU¸ ×ð´ FY09-10 (çßç�æØ ßáü 09-10) FY10-11 (çßç�æØ ßáü 10-11)

Total Income (·é¤Ü ¥æØ)

Net Prot (·é¤Ü ÜæÖ)

Export Revenue (çÙØæüÌ ÚUæÁSß/¥æØ)

MSME AWARD 2015, HARYANA

6. Declaration (�ææðá�ææ)

Page 3 / 4

This is to certify that the above information is true and correct to the best of my knowledge (×ñ´ ØãU â�ØæçÂÌ ·¤ÚUÌæ ãê¢U ç·¤ ©UÂÚUæðQ¤ âê¿Ùæ°¢ ×ðÚUè ÁæÙ·¤æÚUè ·ð¤ ¥ÙéâæÚU âãUè °ß¢ â�Ø ãñ´U)

Enclose a small write up on the Company’s Achievement in the two years, Client’s Testimonials, Marketing Brochure, Bio-Data of the Proprietor / Partner / Promoter, Certicate including SSI / EM registration number & any other relevant information using additional sheets

Name of the Respondent (Âý�Øé�æÚUÎæÌæ ·¤æ Ùæ×)

Designation (ÂÎ) Mobile No. (×æðÕæ§Ü Ù�ÕÚU)

Date (çÎÙ梷¤) Signature (ãUSÌæ�æÚU) Company Stamp (·¤�ÂÙè ·¤è ×æðãUÚU)

(·ë¤ÂØæ çÂÀUÜð Îæð ßáæðZ ×ð´ ·¤�ÂÙè ·¤è ©UÂÜç��æØæð´, »ýæãU·¤ Âýàæ¢âæ-Â�æ, ×æ·ðü¤çÅ¢U», ÕýæðàæÚU, ÂýæðÂÚUæ§üÅUÚU/ÂæÅüUÙÚU/Âý×æðÅUÚU ·¤æ ÕæØæðÇUæÅUæ, °â.°â.¥æ§ü./§ü.°×. ÚUçÁSÅðUþàæÙ Ù�ÕÚU ·¤æ âçÅüUçȤ·ð¤ÅU °ß¢ ¥�Ø â¢Õ¢ç�æÌ ÁæÙ·¤æÚUè °·¤ ÀUæðÅðU Üð¹/çßßÚU�æ ·ð¤ âæÍ ¥çÌçÚUQ¤ ÂëcÆUæð´/ÂðÁ ·¤æ ÂýØæð» ·¤ÚUÌð ãéU° â¢Ü�Ù ·¤ÚÔ´U )

7. Nomination Fees (Ùæ×梷¤Ù àæéË·¤)

Please send a Demand Draft fpr nomination fee. You can also Register & make the payment online at www.dainikbhaskar.com/MSME_awards_of_Haryana

(·ë¤ÂØæ Ùæ×梷¤Ù Ȥèâ ·¤æ çÇU×æ�ÇU ÇþUæ�ÅU ÕÙæ°¢ ¥Íßæ ãU×æÚUè ßðÕâæ§üÅU www.dainikbhaskar.com/MSME_awards_of_Haryana ÂÚU Áæ·¤ÚU ÚUçÁSÅUÚU ·¤ÚÔ´U ß ¥æòÙÜæ§üÙ Âð×ð´ÅU ·¤ÚÔ´U)

Micro Enterprises (âé�× ©Ulæð») Small Enterprises (Ü�æé ©Ulæð») Medium Enterprises (×�Ø× ©Ulæð»)

T500/- T1000/- T2000/-

DD NUMBER DATE DRAW ON AMOUNT

The Demand Draft should be payable to DAINIK BHASKAR at Chandigarh and sent along with the complete application form to the address mentioned below OR submitted at your nearest Dainik Bhaskar ofce. Please mentioned “DAINIK BHASKAR MSME Award-2015, Haryana” on Envelope.(çÇU×æ�ÇU ÇþUæ�ÅU ÎñçÙ·¤ ÖæS·¤ÚU, ¿¢ÇUè»É¸U ·ð¤ Ùæ× âð ÎðØ ãUæð»æÐ Âê�æüÌØæ ÖÚUæ ãéU¥æ Ȥæ×ü çÇU×æ�ÇU ÇþUæ�ÅU ·ð¤ âæÍ Ùè¿ð çΰ »Øð ÂÌð ÂÚU ÖðÁð´/ÂðýçáÌ ·¤ÚÔ´U, ¥Íßæ ¥ÂÙð ÙÁÎè·¤èÎñçÙ·¤ ÖæS·¤ÚU ·¤æØæüÜØ ×ð´ Á×æ ·¤ÚU氢Р·ë¤ÂØæ çÜȤæÈð¤ ÂÚU ÎñçÙ·¤ ÖæS·¤ÚU °×.°â.°×.§ü. ÂéÚUS·¤æÚU 2015, ãUçÚUØæ�ææ çܹÙæ Ùæ ÖêÜð´)

The application form is designed to elicit information for Dainik Bhaskar MSME Awards-2015, Haryana. Your organisation’s nancial information will never

be shared with any other person OR organisation. (§â Ȥæ×ü ·¤æð çßàæðá ÌæñÚU ÂÚU ÎñçÙ·¤ ÖæS·¤ÚU °×.°â.°×.§ü. ÂéÚUS·¤æÚU 2015, ãUçÚUØæ�ææ ·¤è ÁæÙ·¤æÚUè ·¤æð Âý·¤æàæ ×ð´ ÜæÙð ·ð¤ çÜ° çÇUÁæ§Ù ç·¤Øæ »Øæ ãñUÐ ¥æ·ð¤ â¢SÍæÙ ·¤è çß�æèØ ÁæÙ·¤æÚUè ç·¤âè Öè ¥�Ø ÃØçQ¤ Øæ â¢SÍæÙ Ì·¤ ÙãUè´ ÂãéU¿ð»èд)

Please send the completed questionnaires to:

�ÜæòÅU Ù�ÕÚU 11-12, âð�ÅUÚU 25-ÇUè,¿¢ÇUè»É¸U- 160 014

ȤæðÙÑ 0172-3988884Èñ¤�âÑ 0172-2704212, 2709967

Plot No. 11-12, Sector 25-D,Chandigarh-160014

Phone: 0172-3988884FAX: 0172-2704212, 2709967

MSME AWARD 2015, HARYANA

MSME AWARD 2015, HARYANA

8. Awards (ÂéÚUS·¤æÚU)

Page 4 / 4

MSME AWARD 2015, HARYANA

For more information please contact your nearest Dainik Bhaskar ofce at the number mentioned below or email us at : msmeawards@dainikbhaskargroup.com(¥ç�æ·¤ ÁæÙ·¤æÚUè ·ð¤ çÜ° Ùè¿ð çΰ »Øð Ù�ÕÚUæð´ ÂÚU ¥ÂÙð ÙÁÎè·¤è ÎñçÙ·¤ ÖæS·¤ÚU ·¤æØæüÜØ âð â�·ü¤ ·¤ÚÔ´U, Øæ §ü-×ðÜ ·¤ÚÔU )msmeawards@dainikbhaskargroup.com

Disclaimer: Companies and personal information provided by the participatory respondents as mentioned in the application form should be authentic. Disclosers of falsied information will result in exclusion from the award activity. Mandatory eld in the application invitation from should be populated for nomination purpose. Nominations without the mandatory participation fees will not be considered. Awards in each sector and category will be subjected to a minimum number of nominations received. Award methodology and quantitative model is Dun & Bradsteel India's exclusive popularity and will not be shared or disclosed. Award winners are subjected to the discretion of DB Corp. Ltd. and Dun & Breadsteel Information Services India Pvt. Ltd. This questionnaires is the property of Dun & Bradsteel India.

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Register online at:

www.dain ikbhaskar.com/MSME_awards_of_Haryana

SECTOR MICRO SMALL MEDIUM TOTAL

Food & Agro Products 1 1 1 3

Auto Components 1 1 1 3

Apparel, Fashion Garment & Accessories 1 1 1 3

Engineering Goods (including Machinery, Electrical 1 1 1 3and Electronic Goods and Components

Scientic, Measuring & Laboratory Instruments 1 1 1 3

IT & ITeS (except Hardware) 1 1 1 3

Metal and Metal Products 1 1 1 3

Paper & Packaging 1 1 1 3

Handicrafts & Wooden Furniture 1 1 1 3

Textile (Including Readymade garments) 1 1 1 3

SPECIAL AWARDS

Jury’s Special Award for Special Initiatives 1 1

Chief Minister’s Special Award 1 1

Chairman’s Award 1 1

Business Bhaskar Award 1 1

Haryana Emerging MSME Entrepreneur Award 1 1

Best Global MSME Award 1 1

Best Woman Entrepreneur Award 1 1

Best Young Entrepreneur Award 1 1

TOTAL AWARDS 38

dainikdainikbhaskar.com

Dainik Bhaskar, Plot No. 11-12, Sector 25-D, Chandigarh-160014