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APPLICATION FORM FOR FINANCIAL ASSISTANCE
UNDER UNEMPLOYED YOUTH
EMPLOYMENT GENERATION PROGRAMME
't. rdlafurmruugnnflcir Guu.rri
(Name of the Applicant in block letters) ! * rr.9".[. F
2. Onni : Sex (Put /Mark) affi7/",h'" P(gprEr.r6l I ran5genqel
3. Etlop/omrorri Gluuri : Father,s/Husband,s Name

Gcriru+il Gg{r$l5i,
\;ie-f
(g56rfl /Occupation
e e+J',8 Rtr{\J l-qs^ aao
1. (g6om ,Address (Sel0 w"rd116lr;
a) oporurfl t Permanent Address
Elrljgr \qartcr'$,['..rb r{eo$ I

b) peodr ggilu
Goraimgur cfkuncrb
$1uor--r
qe,.osr$ &hGr
Co?respondence Address ajiLrb/Ialuk t\
Mobile No. , Email lD if any. k
eEflSH".*-#:Hu.$-tE rcL r &; lC-oa
c) oL-Sp grd,rgr qeir@onme 6tp,n_mpgr
4rir $d,-o
eflafuronn0rngrir u1g$uidr oudl$g1
&ts*d
er6dlSrioerm?
Whether .esiding continuoulsy for the last thre yeaE
ln the ala from wher loan is applied (put./Mark)
ffi"*,*.. f-l oglit
Religion
ttB-
5. afiJgl otluni) , Age Particulars gneir / Date r.orgti / Month . dr@Lli / Ye.r
a) opSp Gp$l / Date of Birth 't 'o o A t tlA
b) oflairoumddlgLb pnrh gqsi'rpr elu:g1
Age as on the date of application
6. odrfl$ p6$ / Qualification
=3J-v"","
a) edrcsl etru$puncur / Academic
Academic
t5.l-A o21-tv*a^-t oranig
b) 69r$l!uull[dl / Technicat Technical

7. uullfCl ogrb n@gglgnrJrirr gqgei'r ofluair Name of lnstitution

Training undergone, if any
(give name of lnstitution & duration oftraining) Dur?tion

8.
Gosoor0dmrng,eurrn?
g4geuoo$$t{r u$fi,glrirafriocnn? (put /Mark)
94 eunpmrflci'r Gnrenoomiriq g[rb /
- yes/ 6bn6or[ (r)gt6Gg
eraflcir u5tq-nain-ffiE
gflnOu Gonin@rir
Whether the applicant is unemployed? lf so
No
Whether registered with Employment Exchange? u$lal rraiur (l) Er6n
(Give registration No & Date) Ragbtration No. Dats
ollafu emrrirugrrgilg glgrnc0uri u!E6 upugqr86rni Physically Ex- Mlno Taans
9. DI uBc G
/tJl . o, /t6l . rJl . g
ui rr ri / gl ri'r ror n sir
ru.l/ dl un rir at r-o Sew.illan rity gonder
$nngru$glemifu nlEggtpomofl erh/glO,Id.'6r,6ruri
Whather the applicant belongs to SC/ST/BC/MBC
Physically Handicapped/Exserviceman/Minority/
Transgender (PuUMark)
I
10.
gtorio @15ri1gi Op,r$k6ki'r Gluui
Name of Ventur QJl.. <2s rs n ot B, t olitg tnarJ .
gsircoro / oroe / Category(PutlMark) GflUli) Gecoor dlurnrnrnir
lndustry Service Businoss

11. grir gqguorir ogrrr0lgrirSlei,r ollur1ir

Prcvious expe ence in the line of activity, ifany
- ;llgluo& cnci, gt
6hDdm86o{i
 106 gdlirIlLL OEr$lroo nrlp e{lareE@fi Oailr
a.L 6r5fir
12-
E-rhofriorh? (ert-u$$si,r Ouugreir)
;4Ee-Je.t"rl.,-lr
Place of work where the activity as mentioned in Colmn. *)qe>tts , e Ftqoo\dg't'i 7:
10 is proposed to be started (Give full details) ,sfr)ALt^(8 L ,-tCrr) -kt.,-
13. g@6u 4cwr@ olqunrmb (rg$lGroqfl) u$$l[$gL5ir
oflai,nrrrnl5ld;e Goain@rb.
Present annual lncome of the family duly supported by rESAuqp uggtnir
the Affidavit. Rs5.Boza(per annum) @eoemrti;oqrir
14. l&@trq
Gpruroiu@rir
*. 3,066o V
1g9nh@$Clprrns/
@u.r[$lr prnurud;odr / Machinery & Equipment (a) Rs
@gn g4coeu.rnp 6len$gd;orh / Other fixed Assets (b)
Rc
E6DLU)op glogrorrb / Wo*ing Capital (c) 4
Gun$g $hr (g}gntLGS 6lpn6D6 / Total Proiect Cost
(Refer oara I of lnstruction sheet enclosed) 1tRs..,h...aP!P.J s'',1#f:i-,#:frffi.
t5. @
$hr$$[snrm ggahgoir urirdr@$ Glgnros
Owners Contribution proposed to be invested Rs (3o oea
a) Glgn6o5 5% to 10%
of Proiect Cost Rs AE,eoa
b;$lur Lo$Iirr5rgdr r-onnflu.lb oenrru.rEdoriuL-u91. 15%
Subsidy @ l5% of Project Cost. Rs $^rooerta {
c) ouoir Ggnsoo Loan Amount

16. a)6lppg grei,r orirdl / Dp$lu, (s0 Lonpeu gqrra "mipp 615l Yes E NoEH
pgzuonnrooflci.r ougtgo5l Clu$Eshnfrr?
(46) @d:ano)
Whether taken loan from any banking / financial
lnstitution of State / Central Govt. (Put /Mark)

b) g4oiLeurg cusirr GlujdkDuJlrin arrnrw $\qri9 Oerld;fu o$lani

lf yes for l6 (a) whether all repayments made

c)gl5iisrnst errir C)uS$lgridlrir $11ryi0 Clugr$$lu flgleoru Clgnmo

lf no for l6 (a) indicate the balance amount

17. $lpptO fysir unofltr$gtreir e.gu.r ol-dr GluSporn? Y"s ! NoV

Whether availed loan undlr $rb3idy linked Govt. Scheme? ($'b) (@dmo)

Glofrgg5ltifLu nflurnfuoeh g4rorr$g1Lb zanrror-o nrirE Gm$g$ltiLflu@eiror G1gq$lrno g1ona ruadluSki'r grrrGrm/ffi
$lgcurun anflrir g:oGLon er-gpofl ogrtrir Glup opur@ Gairuofldrooo aor cnsirpnfl*dGgir.
Certify that all information furnished by me are lrue and that I have no borowing arrangemenls for ny above proposed
industrial / service/business concern with any bank / rlnancial institution. ,..-
-
L r-fui4sr"f".'[.3
6)L6 (Place): -^-'.1
Enfh (Date) tlil#*'fl1lf,"J'#I
lgdnq :gn$6 Glsriruiuir- $lrnirGl o5larureuurnuniroroenulrir eoe0uLm.rurtrli@, geirGon6 cflnfurcuurnu$$frgi ot$l$6tr p
tqdliq uggl 6-ri: gfln8r@dron 4orrnnireoflri'r perireeoor 6roo"6g GpflGon (g4) gundr 6tnroraGrun
Glungt Gr-orunrrri, Lonclrr Glgngflrir romurir, allgrirqrnb nri,rp ofkunr$$fq g4g[u[uL- Gclaftr@rir.

o FOR OFFICE USE ONLY Recommended Bank

Recommended by Task Force Committee held on
Activity (lndustry / Service / Business
Project cost FR"- Rupees

SUBJECT TO THE CONDITION [ .of getting Proforma-lnvoice 1]of Confirming

the genuity of Supplier 1 ,of getting affidavit, confirming residency of candidate for
alteast three years.
Chairman
TASK FORCE COMMITTEE /
Signature of TFC Members GENERAL MANAGER.

) Amendment made by GM, Dlc o Amendment by Task Force Committee

AmFn.lment annrovcd hv TFC hel.l .ln
change of Bank effected to (as oer BM's I r No DT I
Applicant's/Bank's Lr.Dt.............
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