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| CATR FH CTE GARTOTS SE SAIAAG SYA, SHG A
Bt arate aoa SE cles (Ate)
Society for Self Employment of Unemployed Youth, West Bengal
SWAMI VIVEKANANDA SWANIRBHAR KARMASANSTHAN PRAKALPA (ATMAMARYADA)
ITAMA 7
APPLICATION FORM
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(1 Particulars of the Applicant :
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Photograph Photograph Photograph Photograph
Oa @@ @@ @w
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Name (in Capital Letters) Father's/Mother's/Husband's Name (In Capital Letters)
oa oa
@e) (@)
Oe) (a)
Hy em cs) @)
@®@
“ih tat GcarA ea) “xara trea (Bw aR)
Permanent Adress with Telephone No, any (In Capital Leters)| Present Address with Telephone No, any (In Capital Lerters)
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SE RARE Herre) ahTH ware (crete ers ota firs zr)
ee ne i Date of Bi
fame of concerned Municiplity’Mpl, Corpa/N.A.A. =a
“ogame ee Ca (ato aa en
ow e)@
@Q (9)
(2) @) (2)
(s)@) (8) (4)
(8) (4)
‘reine coma (tare rarer fre zra) orca corary Aafia ser (aeite emtera Ree ere) ie
Educational Qualification Employment Exchange Regn. No. Religion
(Atested copy of supporting documents) (Attested copy of sutorinig acre
oo em foe
@@ @e) @e@
(2) @) (2G) @@)
=
(8) (4) (8) (4) (3a)
(@) 6)
‘won ee Sora a (croft ie feats atiea
ermeera frce xa) hoeblia (core emer froze)
ly Occupation
SCIST Physically Handicepped Monthly Family Income
{Attested copy of supporting daekmens) (Antested copy of supporting document)
oa ow oa
Me Oe O@
(2) @) GB) (9)
(8) (4) (8) 4) (3)
(UD) or5 feaaa :
(ID) Scheme/Project Details :
Ce) Tea eae Crp BoM / Eee / HAI Born):
(6) Business Status (New/Revival/Running) (&) @aeem tbe:
(8) (a) Total Project Cost:
(aie ss tags
(crib erm satya wes)
(b) Amount of Bank Loan :
(65% of Total Project Cost)
(9) Fee parca ofa
(cab ere sats 20%)
(©) Amountof Govt. subsidy
80% of Total Project Cost)
(=) rors arora eee Fae
(carb orem wera ex)
(@) Amount of Own contributation
(6% of Total Project Cost)
(8) 00 cores aoa er, GRA (SE Bens CCS) 3
(©) Present Address with Telephone No,,[fany, of Business Place (In Case of Running Business):
() qeftececmeaBemts
() FullAdéress ofthe Proposed Project:
Go) eal etre aca fora / erp / Free ce eran (wey meine rate Rear cw ec) =
(10) Proposed Project tobe located on own /hired ease land ete, (Details tobe furnished with supporting document)
(I) eeatey fara s
(IID Other Details :
TORTS EER anal Need ie are often areTe Fe
aoe % (ee era seats eae xa)
‘Name of the Govt. sponsoted programme Amount of Govt. subsidy
in which Govt. subd Sate whether loan with interest hasbeen fly
received previously . repaid (Necessary documents to be furished in
‘support of repayment)
OM ea net a, era
‘Tothebest of my knowledge the i
Sea vances ar
‘Name & Signature in full of the Prakalpa Sahayak
ee
HaCaT are ASAT MTS SRR ATTOTRETA SA
Signature ofthe M. SHG BSE O/B, SHG & SE.O/Block SHG & SE Ofcer/Supervisor
