DISTRICT INDUSTRIES CENTRE Government of Andhra Pradesh APPLICATION FORM FOR THE EDUCATED UNEMPLOYED YOUTH UNDER "PRIME MINISTER'S ROZGAR YOJANA" SCHEME Name of the Bank/Branch : 1. Name of the Applicant : 2. (a) 1.Name of the Applicant : (b) Husband's Name : (In case of married women) 3. Date of Birth and Age : 4. Detailed place of Residental during last three years : 5. Qualifications (a) General : (b) Technical : 6. Employment Regn. No. & Date if any : 7. Whether the applicant belong to SC/ST/BC/Min/PH/Service/ Business /Women : 8. Type of Industry/Service/Business activity : 9. Present annual income of the family duly supported by proof : Rs. 10. Amount of loan required for (a) Machinery & Equipments : Rs. (b) Other fixed assets : Rs. (c) Working Capital : Rs. (d) Total : Rs. 11. Whether taken loan from any Bank/ Financial institution, of State/Central Govt. (Details in brief to be furnished) I certify that the above information furnished by me is true. Signature of the applicant. Encl: Application in duplicate along with copies of following certificates: 1. Educational Qualifications Certificates. T.C/S.S.C/I.T.I 2. Age certificate - TC -SSC Certificate 3. Certificate of previous experience if any. 4. Physically Handicap Certificate if applicable. 5. Caste Certificate from Mandal Revenue Office, in the case of SC/ST or BC if applicable. 6. Ex-Serviceman if applicable. 7. Income Certificate from M.R.O./Gazatted Officer. 8. Ration card held by the family or residence certificate from M.R.O/Gazatted Officer 9. Affidavit on plain paper as enclosed. 10. Recent Passport size photos(2) affixed Eligibility: 1. 8 th Class and Above 2. 18-35 years and 10 years relaxation for SC/ST/PH/Women/Ex-servicemen 3. Family annual income below Rs.40,000/- AFFIDAVIT (On Plain Paper) Not to be Notarized I..........................................S/o.D/o.W/o............................. Do hereby solemnly affirm and declare as under: 1. That I am Unemployed. 2. That I am not in a position to muster my own capital for the Project. 3. That I am a permanent resident of H.No............................................ Since .........................................years 4. That the family income of my family which includes spouse and parents Rs.................... per annum from all sources such as salary, wages, agricultural income, business, rent, interest, pension etc., 5. That I have not defaulted in repayment of loan from any Nationalized Bank /Financial Institution, Co-op Bank. 6. That I shall abide by the rules framed under the scheme of PMRY for Educated Unemployed Youth. 7. That I shall submit the progress report required by the Bank/Govt. 8. That I am liable for prosecution if the furnished information is found false. 9. I or any members of our joint family have not availved any loan earlier from any Government Sponsored including PMRY 10. had not applied for loan under PMRY to any other Bank. This is the only application now being preferred Deponent (Applicant) SPECIMEN COPY (Candidates to obtain the below mentioned certificates separately) FAMILY INCOME CERTIFICATE This is to certify that Sri/Smt................................................................,, S/o, D/o, W/o ...................................................................................... R/o.H.No. .............................................. is residing in above Address and his/her family annual income is Rs......................(Rupees.... ...................................) from the following sources. a) Salary b) Agriculture c) Business d) Rent e) Pension f) Others(specify) I know him/her well with the best of my knowledge and hence this income Certificate is issued under G.O.Ms.No.554, dated: 2-8-1988 Revenue(A) Dept., and G.O.Ms.No.286, dated:28-11-1988, Social Welfare Department. Place: Signature of Gazatted Officer Date: With stamp CASTE CERTIFICATE This is to certify that Sri/Smt................................................................ S/o. D/o. W/o. ................................ of village/town .......................... Mandal ...................................in the District of .............................. in the State of A.P. has been verified as per the procedure laid down and he/she belongs to ........................................ community, which is recognized as Schedule Caste/ Schedule Tribe/Backward Class under group ....................... as SI.No............................................. Place: Signature of Gazatted Officer Date: Office Seal RESIDENTIAL CERTIFICATE This is to certify that Smt./Kum./Sri....................................................... S/o.W/o.D/o....................................R/o.H.No....................................is residing in the above address since.........................................years. I know him/her well with the best of my knowledge Hence this certificate is issued under G.O.Ms.No.554,dated 2-8-1988,Revenue (A) Dept., and G.O.Ms.No.178, Dated: 6-8-1988 Social Welfare (32) Dept., G.O.Ms.No.286, Dated:28-11-1988, Social Welfare Department. Place: Signature of Gazatted Officer Date: Office Seal:
