PM Vishwakarma
(Registration Form)
Personal Details
Full Name Father/Spouse Name Date Of Birth
Meesala Gangabhavani W/O Meesala Krishna Rao 18-04-1984
Marital Status Gender Category
Married Female OBC
Divyangjan Business in same state?
No Yes
Business in same district? Minority?
Yes No
Contact Details
Mobile No. Aadhaar No. PAN Card
6302775847 XXXXXXXX0448 N.A.
Family Details
Ration Card No.
N.A.
Name Relationship Aadhaar No.
MEESALA GANGABHAVANI SELF xxxxxxxx0448
MEESALA KRISHNA RAO HUSBAND xxxxxxxx9215
Aadhaar Address
Aadhaar Address
C/o: W/O Meesala Krishna Rao House: - Loc: paravada vtc: Paravada Street: desapatrunipalem State: Andhra Pradesh pc: 531021 dist: Visakhapatnam
Country: India
State District Pin code
ANDHRA PRADESH VISAKHAPATANAM 531021
Do you Come under Gram Panchayat? Name of ULB
No GVMC
Current Address
Current Address
C/o: W/O Meesala Krishna Rao House: - Loc: paravada vtc: Paravada Street: desapatrunipalem State: Andhra Pradesh pc: 531021 dist: Visakhapatnam
Country: India
State District Pin code
ANDHRA PRADESH VISAKHAPATANAM 531021
Do you Come under Gram Panchayat? Name of ULB
No N.A.
Profession/ Trade Details
Profession / Trade Name
Sub Category
Tailor (Darzi)
Business Address
C/o: W/O Meesala Krishna Rao House: - Loc: paravada vtc: Paravada Street: desapatrunipalem State: Andhra Pradesh pc: 531021 dist: Visakhapatnam
Country: India
Business State Business District
ANDHRA PRADESH VISAKHAPATANAM
Saving Bank Details
Name of Bank IFSC Code Name of Branch
Andhra Pradesh Gr.Vikas Bank APGV0003305 PARAVADA
Account No. Confirm Account No.
XXXXXXXXXXXXXX0184 1020260184
Credit Support
Do you want Credit Support? Loan Amount Required (1st Tranche) Preferred Bank to Take Loan
No 0 N.A.
Preferred Branch to Take Loan Loan Purpose Purchase of Equipments
N.A. No No
Working Capital / Operating Expanses Business Expansion Outstanding Amount (in Rs.)
No No N.A.
Existing Loan Monthly EMI Amount (in Rs.) Total Monthly Family Income (in Rs.)
N.A. N.A. N.A.
Digital Incentive Details
Are you Digitally Active? UPI ID UPI ID Linked Mobile Number
No N.A. N.A.
Skill Training
You are eligible for skill training for below training programes.
Basic (5 Days) Skill Training
Advance (15 Days) Skill Training
Tool Kit
Once you are registered and skill training certified you will be given a grant of ₹15,000
Marketing Support
Marketing Support question that applies to your business expansion
Declaration Details
Declaration and Authorization
1. I hereby declare that I am engaged in the trade as indicated in the application form.
2. I hereby declare that apart from myself, no other member of my family has registered for PM Vishwakarma and that no member
of my family is in government service.
3. I have no objection to authenticate my Aadhaar number, share the same with other Ministries / Departments under the
Government of India or the State Government for the purpose of extension of benefits under any of their Schemes, carry out e-KYC
and accessing my credit history & credit score from credit bureau by the lenders and their authorized agents. The consent and
purpose of collecting Aadhaar has been explained to me in local language. MoMSME/Lending Institution has informed me that my
Aadhaar submitted herewith shall not be used for any purpose other than mentioned above, or as per requirements of law. I have
been informed that this consent and my Aadhaar will be stored along with my account details with MoMSME or their authorised
agent as per the extant law.
4. I hereby agree that my application may also be processed for availing Udyam Assist Certification which will enable me for Priority
Sector Lending (PSL) benefits.
5. I hereby declare that information given above is true to the best of my knowledge. I am well aware of the fact that, if the
information given by me is proved false/not true, I will be liable for action as per the law. Also, all benefits shall be summarily
withdrawn.
Date : 20/01/2024 Signature of Applicant(s)
Place : VISAKHAPATANAM
