ANNEXURE

OFFICE OF THE DEVELOPMENT COMMISSIONER

(SMALL SCALE INDUSTRIES)
MINISTRY OF SMALL SCALE INDUSTRIES
GOVERNMENT OF INDIA

TRADE RELATED ENTREPRENEURSHIP ASSISTANCE & DEVELOPMENT

(TREAD) FOR WOMEN
APPLICATION FORM

1. DETAILS OF NON-GOVERNMENTAL ORGANISATION (NGO)

i.) Name

ii) Full Address with Pin Code

P I N

Tel. Nos

E-mail:

iii) Name and Designation of Chief Functionary, address with contact details,
 iv) Names of other key functionaries, their addresses and contact details

v) Registration No. &Date

(Enclose a copy of the Registration Certificate)

vi) Main objectives as given in Bye-laws

vii) Whether provision is there in Bye-laws to undertake borrowing and

lending activities - Y/N

(Enclose a copy of the Bye laws)

viii) Copies of audited balance sheet for preceding last 3 years

ix) Copy of latest Annual Report

2. ORGANISATIONAL SET UP

i) Office Staff (No.)

ii) Field Staff (No.)

iii) Supervisory Staff

3. MAJOR PROJECTS IMPLEMENTED & FUNDS RECEIVED DURING

LAST 3 YEARS (RS. LAKH)

Year Grant Received Loan Received

Amount Organisation Purpose Organisation Amount Amount Purpose
From from Recovered
Received
4. DETAILS OF PRESENT PROJECT PROPOSALS

i) Objectives of the project

ii) Proposed income generating activities
iii) Place of implementation of the project
iv) No. of beneficiaries of the project
v) Proposed means of Finance of Project Cost
(Give all the details on separate sheets)

5. PROPOSED FUNDING & AMOUNT OF GoI GRANT SOUGHT UNDER

EACH ACTIVITY OF THE PROJECT

Name of No. of Average loan Total loan Average Total

Activity borrowers amount per required GoI GoI
borrower (Rs.lakh) amount required
per (Rs.lakh)
(Rs. lakh)
borrower
(Rs. lakh)

6. EXPECTED LEVEL OF BENEFIT AFTER COMPLETION OF THE PROJECT

INCLUDING ANTICIPATED MONTHLY INCREASE IN INCOME OF THE
BORROWERS/BENEFICIARY WOMEN
(Give a write up with projected details)
 7. PROPOSED REPAYMENT SCHEDULE
(Enclose repayment schedule statement)

8. Please indicate the Bank through which the proposed loan is to be raised :

Canara Bank/ Syndicate Bank/ State Bank of India

Declaration :
I hereby certify that the above information furnished by me is correct. I
undertake to use the Government of India grant component and the loan
component received from lending agencies for the intended purpose of
empowerment of women beneficiaries for their self-employment through non-farm
activities as proposed above. I also undertake to sincerely monitor the utilisation of
assistance under the scheme. I promise to repay the loan component as per the
repayment schedule proposed above or the same as fixed by mutual understanding
of the undersigned and the lending institution. In case of the failure of the project I
promise to refund both the GoI grant and the loan amount received under the
scheme. Further I may also be liable for penal action under the law of land for any
false declaration.
Signature

Name

Designation in the NGO

Place

Date

Seal of NGO

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