APPLICATION FORM FOR CREDIT FACILITIES

OF OVER 2 CRORES

I/We apply for financial assistance of Rs. ______________________ for __________________

(purpose) and give details in this behalf:

A.

1) Name of the Individual/ Enterprise (In block letters) ________________________________________

2) Constitution : Individual/ Proprietary /Partnership Firm/Pvt Ltd. Co. / Co-operative Society

(Please strike out which are not applicable).

3) Name of the group (if any)

4) Registration No.
[ as given by the District Industries Centre/Directorate of Industries- Discretionary for Micro and Small
Enterprises, Mandatory for Medium Enterprises (Mfg)]

5) Date of Establishment
GST registration – Yes/no
GST registration no. (If yes):
PAN card no.:

6)
a) Business Address with Telephone/.Landline/Mobile telephone number and email id

b) Registered Office

c) Administrative Office

d) Factory/Godown/Shop

7) Whether the applicant belongs to SC/ST/OBC/Minority Community (in case of individual)

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8) Proprietor / Partners/Directors of the Company and their particulars.
i) Name
ii) Qualifications
iii) Age
iv) Residential Address

v) Contact Tel No.

Landline Mobile No
E-mail id
vi) PAN card no.

9) Brief Description of the Industrial Activity

a) Existing

b) Proposed
10) If the unit is an ancillary unit, the undertaking to which it is catering and its address

11) Name of associate concern(s), if any

12) No. Of persons Employed Present Proposed

Executive
Supervisory
Administrative/Office Staff
Skilled Labour
Unskilled Labour
B
13) How the Activity was financed so far
(To be filled up in case of existing unit only)

14) Credit Facilities (Existing) Rs. in lakhs

Type of facilities Limit Outstanding Presently Security ROI Repayment
as on _____ banking with lodged terms

Current
account/Overdraft

Cash Credit
Term Loan
LC/BG

If banking with Bank of India, customer no. to be given here _______________________

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15. PAST PERFORMANCE/ FUTURE ESTIMATES( Actual performance for two previous years,
estimates for current year and projections of next year to be provided for working capital facilities.
However for term loan facilities projections to be provided till the proposed year of repayment of loan.)
Rs in lakhs Past year – Past Year –I Present Year Next Year
II(Actual) (Actual) (Estimates) (Projections)
[Link](Net
worth in case of
companies)
[Link] debt
a) from
promoters, friends
& relatives
b) from Banks &
Financial
Institutions
[Link] Sales
[Link]
[Link]
[Link]
[Link]
Profit/Loss

16. Contingent Liabilities

17. Status regarding statutory obligations

Statutory Obligations Whether complied Remarks
with(Write yes/no).If not
applicable the write NA

1. Registration under Shops &

Establishment Act

2. Registration under MSME Act

( Provisional/Final )

3. Drug License
4. Latest Sales Tax/VAT Return Filed
5. Latest Income Tax Return Filed
6. Any other statutory dues remaining
outstanding

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18. Arrears in Statutory Payments (if any)

a) Income Tax

b) Sales Tax/VAT

c) Provident Fund

d) Employees State
Insurance Corporation

e) Others (specify)

19.1 Nature of activity and items manufactured

19.2 Promoter’s experience

D
20. TECHNICAL FEASIBILITY

20.1 Name of the Product(s), including bye-products and its (their) use:

20.2 Manufacturing Process, in brief.

20.3 Capacity (No of units. Quantity in kg./volume in litre p.a.)

Capacity for each Licensed Installed Operating

product

No. of working days in a month

&
No. of shifts in a day

20.4 Locational advantages of existing and/or proposed

Premises with reference to (absence of civic restrictions, proximity to the source of raw material,
market, power, water, labour, transportation etc.)

20.5 Whether clearance has been obtained from the

Pollution control authority

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20.6 PARTICULARS OF MACHINERY AND OTHER FIXED ASSETS

As per Annexure II

20.7 Necessity & purpose for the proposed investment/)

20.8 RAW MATERIALS/ COMPONENTS

(Please mention about the imported and indigenous items separately)

20.9 Major suppliers of Raw Materials

21. UTILITIES
(Give comments on requirement, availability/adequacy, qualitative aspects etc.)

21.1 Power:

Contracted Load

Connected Load

Future power consumption

(In no. of units) per month

Stand-by Arrangements

(Enclose certified Xerox copy of sanction for power connection)

21.2 Water
(Enclose certified Xerox copy of sanction of water connection)

21.3 Fuel

21.4 Others (specify)

22. Market for the product (mention separately for each product scope, geographical markets and
competition, orders in hand, major potential customers etc.)

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23. Cost of Project
(Please furnish estimates of cost of project under the following heads.
Indicate the basis for arriving at the cost of project)

(Amount in Lacs)
Sr No Particulars Already incurred To be incurred Total Cost
A Cost of Land including
development
B Building & Other Civil
Works
C Plant & Machinery
1) Indigenous
2)Imported
D Essential Tools, Spares
and Accessories
E Testing Equipment
F Misc. Fixed Assets
G Erection/Installation
charges
H Preliminary Expenses
I Pre-Operative Expenses
J Provision for
contingencies
1) Buildings
2) Plant & Machinery
3) Other Fixed assets
K Margin for Working
capital reqd.
L Total

24. Means of Financing

(Please furnish details of sources of finance for meeting the cost under the following heads)
(Amount in Lacs)
Sr No Particulars Amount already Amount proposed to be Total
raised raised
A Capital
(specify resources
contributing capital
B Reserves
C Term Loans
(give full particulars)
D Unsecured Loans
E Subsidy/Seed capital
F Others
G Total

24.1 Promoter’s contribution to the project

As % of the total cost
(Please furnish list of persons/firms who
Would be contributing to the promoter’s
Share of the capital and the respective
Amounts and their relationships)

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25. Schedule of Implementation
Please indicate the progress made so far in the implementation of the project and furnish the
schedule of implementation as follows:

Date of Expected Date

Commencement of Completion

a) Acquisition of Land

b) Development of Land
c) Civil works for
Factory building
Machinery foundation
Administrative building

d) Erection of equipment

e) Commercial Production

26. Future Projections

Please furnish data on

26.1 Projected profitability as per Annexure III

26.2 Projected Balance Sheet as per Annexure V

26.3 Working Capital Requirement Annexure VI

27. Nature of Financial Assistance Required

27.1 Term Loan

27.2 Working Capital

Previous year Current Year

a. Gross Sales
b. 31.25% of Gross Sales
c. 6.25% of Gross Sales
d. Actual /Projected Net Working Capital
e. (b-c)
f. (b-d)
g. Permissible Bank Finance*
(Lower of e & f)

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27. 4 Non-Fund based limits,
i.e. other forms of assistance
(e.g. L/Cs, bank guarantees, etc)

28. Repayment Programme:

29. Details of securities to be offered:

29.1 Primary
(Working capital and term loan securities to be indicated separately)

29.2 Collateral, if any (full details) (No Collateral Security required if the account is covered under
credit guarantee scheme of CGTMSE)

29.3 Details of guarantors(s) (No third party Guarantor is required if the if the account is covered under
credit guarantee scheme of CGTMSE)

29.3.1 Name & Age:

29.3.2 Residential Address

29.3.3 Occupation
(If in service, name & address of his/her employer)

29.3.4 Details of Movable& Immovable property (ies)

Owned by him/her & other dependent family members

29.3.5 Details of any similar guarantee, if any, given

To other institutions

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30. Whether any government enquiry, proceedings or
Prosecution has been instituted
Against the unit or its proprietor/partners/directors
For any offence? If so, please give details.

31. Details of pending litigation, if any, against and by the unit.

32. Relationship of Proprietor/Partner/Directors with the officials

Of the Bank/Directors of the Bank

33. Please indicate whether the proprietor/any of the

Partners/promoters/directors have at any time
Declared themselves as insolvent.
If so, give details thereof

I/We certify that all information furnished by me/us is true; that I/We have no borrowing
arrangements for the unit with any Bank except as indicated in the application; that there is no over dues/
statutory dues against me/us/promoters except as indicated in the application; that no legal action has
been/ is being taken against me/us/promoters; that I/We shall furnish other information that may be
required by you in connection with my/our application; that this may also be exchanged by you with any
agency you may deem fit; and you, your representative, representatives of the Reserve Bank of
India/National Bank of Agricultural & Rural Development/Small Industries Development Bank of
India/Credit Guarantee Trust for Micro and Small Enterprises/Credit Information Bureau of India Ltd. or
any other agency as authorized by you, may at any time, in respect/verify my/our assets, books of
accounts, etc in our factory/ business premises as given above.

Date: ____________________________

Place: Signature of the Borrower

(Name & Designation)

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Encl: Certified Xerox copies of

a) Audited Balance Sheets with Trading Profit & Loss account, for the last three years.

b) Memorandum and Articles of Association, Certificate for Commencement of Business. (if applicable)

c) Income Tax, Returns and the assessment orders for last three years, for the unit as well as
proprietor/partners/promoters/directors.

d) Sales Tax/Service Tax Returns for the last three years.

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 BIO-DATA FORM
Annexure-1

Details of Proprietor / Partners / Managing Partner /Promoters / Managing Director.

(Please indicate inter-relationship, if any, among the partners/directors/promoters)
(Please use separate sheet for each person)

1. Full Name

2. Name of the Father/ Husband.

3. Age

4. Sex

5. Experience:

Years Employer Designation Last Salary

Drawn

6. Reasons for joining /establishing the unit

(Please mention about the motivating factors)

7. If associated as proprietor/partner/director/
Shareholder with concerns other than the applicant unit,
Please furnish following details separately for each concern
By way of enclosure.

7.1 Name and address of the branch/associates/

Identical concern.

7.2. Activity of the concern.

7.3 Name of the associate concerns

Banker and their address.

Signature
Place:

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Annexure-II
Details of Existing Fixed Assets

Land

1. Location

2. Area

3. Whether Freehold or Leasehold

4. Purchase Price of Land if owned

5. Rent in case of lease land

6. Terms of lease

7. Ground Rent payable per year

Building

1. Location
2. Whether Owned or Leased
3. Purchase Price of Land if owned
4. Rent in case of Leased/Rented Premises
5. Terms of Lease

Structure Type of Dimensions Area Actual Cost Date of Erection

Structure (In Sq. Mtr.) (in Rs.)
(Indicate “P” If
Permanent)
1) Workshop

2) Godown

3) Administrative

4) Other Buildings

In case the assets have been revalued or written up at any time during the existence of unit, furnish full details of
such revaluation together with the reason therefore.

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Particulars of Buildings Proposed to be constructed

Proposal Description Type of Total Rate of Estimated Expected

No of each construction Built –up Areas (in Meters) Floor Construction cost of date of
Building in per sq m each completion
Length Breadth Average Sq. building
Height mtr.

Note: [Link] case contract is awarded for construction of building, furnish details thereof such as name of contractor,
amount of contract, etc
2. Other approvals from inspector of factories, drug controllers, etc, if any, should be enclosed
3. Please enclose a plan showing layout of machinery.

Particulars of Machinery-

Name of Secon Name of Date of Expecte Invoice price Estimated Total

Machinery & d Manufacturer/Fabricator(Plac acquisition/ d date of including expenses cost
Specification Hand / e of country and origin, if Date of delivery taxes for of
New Imported) placement indigenous insurance,
of machinery/CI freight,
order(actual F for imported installation
/ expected) Machinery , import
duty
Existing
Machinery
1.1Indigenous

1.2Imported

Proposed to
be acquired
2.1Indigenoiu
s
2.2 Imported

Quotation/Catalogues/Invoice and other details in respect of each machine to be furnished

If second hand machinery, valuation report regarding age, performance and value from competent valuer to be
submitted. Also please indicate reasons for going in for second hand machinery and its depreciated value.
In case the assets have been valued or written up at any time during the existence of unit, furnish full details of
such revaluation together with the reason therefore.
Annexure-III

Projections of Performance, Profitability and Repayment-

Break -even point Break-even Quantity

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% of Installed Capacity Break –even Value
(Figures in Lacs)
st nd rd
1 Year 2 Year 3 Year 4th Year 5th Year
Production during the year (Quantity)
% Utilization of installed capacity
Sales
[Link] including all miscellaneous
[Link] Excise
[Link] Sales
Cost of Production
[Link] material consumed
[Link] & Fuel
[Link] labour & wages
[Link] Stores
[Link] & Maintenance
[Link] Manufacturing expenses
[Link]/ Development Rebate
Reserve
Total Cost of Production
[Link] opening stock-in-process & finished
goods
[Link] closing stock-in-process &
finished goods
Cost of Sales
Gross Profit (B-D)
Interest on
1. Term Loans
2. Working Capital
3. Other Loans if any
Selling, General & Administrative
Expenses
Profit before Taxation {E-(F+G)}
Provision for Taxes
Net Profit (H-I)
Depreciation added back
Net Cash Accruals
Repayment obligations
1. Towards Term Loan
2. Towards other Loan, if any.
Total Repayment
Debt Service ratio (L:M)

Projected Balance Sheet-

1st Year 2nd Year 3rd Year 4th Year 5th Year
A Liabilities

1. Equity Share Capital

[Link] & Surplus

3. Term loans

[Link] Borrowings for Working Capital

5. Other liabilities

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Total Liabilities
B Assets

1. Gross Block

[Link]

3. Net Block

[Link]

5. Current Assets

6. Cash & Bank Balances

Total Assets

Annexure

Land & Building

Enclosure:
a) Certified Xerox copy of sale/lease deed

b) Certified Xerox copy of the Govt. order converting the land into industrial land, if applicable.

c) Location map

d) Certified Xerox copy of site plan of the land and blueprints of the buildings duly approved by
corporation/ municipality/ Panchayat.

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