Annexture -I

Society for Self Employment of

Unemployed Youth, West Bengal

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Bangla Swanirbhar Karmasanasthan
Prakalpa (ATMAMARYADA)

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APPLICATION FORM

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Particulars of the applicant

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1. Name (In Capital letter)

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2. Father's / Husband's Name

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3. (a) Full permanent address with

Telephone No. if any (In capital letter)

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(b) Present full address with Telephone

No. if any (In capital letter)

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4. Date of Birth (attested copy of supporting

documents)

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5. Educational qualification (attested copy of

supporting documents)

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6.

Employment exchange Regn. No. (attested

copy)

7l

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7.

SC / ST / PHE (attested copy of supporting

documents)

8l

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8.

(a) Family occupation

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(b) Monthly family income (attested copy of

supporting documents)

II

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II

Scheme / Project details

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9.

Business status : (New / Revival / Running)

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10.

Short description of the proposed scheme

(Name of the scheme etc.)
(details to be furnished in separate sheet)

11l

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11.

(a) Total project cost

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(b) Bank loan component

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(c) Present address with Telephone No. if any
of business place : (In case of running business)

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12.

Full location address of the project

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([Y[ [ [| |)

13.

Project to be located on own, hired /

lease land etc. (details to be furnished)

III

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(III) Other details

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14.

(a) Whether received any loan previously

under Govt. sponsored programme

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(b) If yes, then amount of subsidy received

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(c) State whether loan with interest has been

fully repaid (necessary documents to be
furnished in support or repayment)

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Undertaking

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llllllllllllllllllllllllllllllll | &ZY [T {, }Y {| YY Y [^q| Y
(Exchange Card) Hm[ _Y| \ ^|Y | Y[Y| [ YY | } ^
_ [|Y| Y[ [ YY [Y \YY | {Y |. [Y| |\
Y[ {Y }Y| \ }Y { Y Y YY [YZ Y.
The above statement is true to the best of my knowledge and belief. I, Shri / Smt.
........................................................do hereby undertake that the Employment Exchange Card will be
kept in abeyance in the event of sanction of loan for execution of the scheme and that the abeyance
will be lifted only after the loan with interest has been repaid in full. During the period of abeyance
of the cards I shall not be entitled for any employment call from the Employment Exchange.

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llllllllllllllllllllllllllllllllllllllllllllllllllllll
(Y|YZ O>Y)
(Full signature of the applicant)

To the best of my knowledge the

information furnished by the
applicant is true.

.........................................................
.........................................................
.........................................................

(Y| D_ Y } O>Y)

(|a / {Y|Y ^ Y[Y[| O>Y)

(Name & signature in full of the

Motivator)

(Signature of the M. Y. O. / Br. Y. O.)

(Hm _Y [[ \)
(Remarks of the project
implementation committee)