GOVERNMENT OF ASSAM DIRECTORATE OF INDUSTRIES & COMMERCE, ASSAM Application Form for Permanent Registration as Small Scale Industries (To be filled in Triplicate) FORM 1. Provisional Registration No. 2. Date of issue of Registration 3. Date of commencement of Production 4. Name of Unit/Applicant 5. Address for Communication. Telephone Pin Code 6. Category of Unit SSI - 1/ ANC - 2/ SSSBE - 3/ Tiny - 4/ EOU - 5. 7. Location Village/Town Post Office District State 8. Area of Location Rural-1/ Urban-2/ Metropolitan-3 9. Type of Organisation Proprietory-1/ Partnership-2/ Private Co.-3/ Co-operative-4/ Others-5. 10. Nature of Activity Manufacturing /Assembling-10 /Processing-2/Job Work-04/ Repairing/ Servicing-08 11. Main Items of Manufacture/ Activities (Details of Capacity to be furnished in "Appendix-A") (i) Name Code (ii) Name Code (iii) Name Code (iv) Name Code (v) Name Code 12. Investment in Fixed Assets (Rs. in 000) (i) Land (ii) Building (iii) Plant & Machinery (iv) Other Fixed Assets Total 13. Investment in Plant & Machinery (Original value Rs. in 000) (Details to be furnished at "Appendix-B") 14. Raw Materials Requirement Name of raw-materials Item Code Indigenous-2 Imported-1 Annual Value (RS.in 000) Consumption V. Other Raw Materials 15. Sources of Power Coal-01/ LPG-04/ Oil-02/ Electricity-08/ Non Conventional Energy-16/ Traditional energy/Firewood-32. 16. Power Load H.P. (1 HP = 0.796 Kw.) K.W. 17. Employment (a) Managerial & Office staff (b) Supervisory & Workers (c) Total 18. Whether Registered under Factories Act? If Yes-1, If No.-2 19. Applicant's Profile Male-1, Female-2. SC-1, ST-2 Engineering Graduate-1 Other Graduate-2, Other-3 Date Signature of Applicant Name of the Proprietor/Partner/Managing Director FOR OFFICE USE ONLY Application No. NIC Code Block Code District Code State Code Whether the items of manufacturing activity require an Industrial Licence? If Yes-1, If No.-2 No Industrial Licence is required for items listed Schedule-2 of licensing notification dated 25-7-91, if the unit employs less than 50/100 with/without power. CERTIFICATE OF REGISTRATION ADDITIONAL SHEET: 1 Registration No.: Date of issue: Additiona/Deletion in Plant & Machinery Serial No. 1. Name of Machinery Added/Deleted Date of effect Original value Rs.in 000 2. 3. 4. 5. Revised value of investment in Plant & Machinery (Serial No.14) (Rs.in 000) Change in location (Serial No.7) Changes in constitution/Type of Organisation (Serial No.9) Date: Signature Name & Designation of Registering Authority APPENDIX-A For any combination add the respective code Serial No. 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 (Value Rs.in 000) Product & by-products Product Unit of Unit Annual Capacity Manufactured/ Assembled & Service sold code Quantity code Quantity Value Manufacturing/ Assembly Other Product & By-product (Combined) Total (1 to 5) Processing Others (Combined) Total (7 to 10) Job Works Servicing Repairing Total (12 to 14) Grand Total (6+11+15) Details of Plant & Machinery APPENDIX-B Sl. No. Name of the Machinery Number Imported-1 Indigenous-2 (Rs.in 000) Cost (Original value
