ANNEXURE - IV (A) GOVERNMENT OF ORISSA DIRECTORATE OF INDUSTRIES APPLICATION FORM FOR PERMANENT REGISTRATION AS SMALL SCALE INDUSTRIES (TO BE FILLED IN TRIPLICATE) 1. Provisional Registration No. : 2. Date of Issue : 3. Date of Commencement of Production : 4. Name of Unit/Applicant : 5. Address for communication : At. : PO : Dist. : Tel : Pin : 6. Category of Unit : SSI-1, ANC-2, SSSBE-3, TINY-4, EOU-5 7. Location : Place/Town : Tahsil/Taluk : Distict : State : 8 Area of Location : Rural01, Urban-2, Metropolitan-3 9. Type of Organisation : Proprietory-1, Partnership-2, Company-3 Co-operative-4, Others-5 10.Nature of activity : Manufacturing/assembling (01) Processing (02) 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.'000) (Details to be furnished at Appendix 'B' : 14.Raw Material requirement : Name item Code Imported-1 Annual Consumption Indigenous-2 Valu (Rs. in 000.00) i. ii. iii. iv. v. Other raw materials Total (i. to v.) 15.Source of Power : Coal-01, Oil-02, LPG-04, Electricity - 08 Non-convention energy-16, Traditional energy. Fire Wood-32. 16.Power Load, HP (1 H.P.=0.795Kw) Kw 17.Employment. (a) Managerial & Office Staff : (b) Supervisory and Workers : 18.Whether Registered under Factories Act Yes-1 No-2 19.Applicant's Profile Male-01 Female-2 SC-01 ST-02 Engineering Graduate-1, Other Graduate-02 Other - 03. Date: Signature of Applicant Name of Proprietor/Partner/Managing Director. FOR OFFICE USE ONLY Application No. : NIC Code.: Block Code.: Distric Code : State Code: Whether the items of manufacture/activity require an industrial licence. Yes-1, No-2. (No Industrial licence is required for items listed in schedule II of the licencing notification dated 25-07-1991 if the unit employs less than 50/100 workers with/without power. ANNEXURE - IV(B) CHECK LIST DOCUMENTS SUBMITTED ALONG WITH THE APPLICATION FORM FOR PERMANENT REGISTRATION. (TICK OUT) 1. Photostat copy of the documents proving legal ownership or lease of the land on which the unit is established. 2. Copies of vouchers - all plant and machineries. 3. Certified list of all plant and machinery including installation, electrification, Generator, Transformer, Tools, Zigs, Moulds, dies indicating specification and cost of each in possession of the owner and any other unit under the same ownership signed by the owner. 4. Copy of agreement with OSEB. Copy of Energisation certificate i.e. date of line charged and first Electric bill. 5. Copy of statutory licence of permission from appropriate authority (Municipality, NAC, Cinema Hall, Explosive Licence drug licence, Cold storage, no objection certificate from SPCP Board etc. 6. Copy of Original PRC. 7. Copy of sanction letter from financial Agency. 8. Copy of article of association and incorporation certificate from Joint Stock Company or partnership deed for partnership firm. 9. Copy of first purchase raw material bill. 10. Two Passport size photograph of promoter. 11. Certified that I will show original vouchers and documents to the verifying Officer at the time of inspection. Date Signature of the applicant to Official seal APPENDIX-A For any combination and the respective codes (Value in Rs. '000) Sl Product & by-products product unit of Unit Annual Capacity No. manufactured/ assmbled code quantity code quantity value & service sold -------------------------------------------------------------------------------------------------------------------------- 01. Manufacturing/assembly 02. 03. 04. 05. Other Prd, & by-prd(comb) 06. Total (1 to 5) X X X X X 07. Processing 08. 09. 10. Others(Combined) X X X 11. Total (7 to 10) X X X X 12. Job Work X X X 13. Serviving X X X 14. Repairing X X X 15. Total (12 to 14) 16. Grand Total(6 +11+15) X X X X APPENDIX - B DETAILS OF PLANT AND MACHINERY Sl. No. Name of the machinery No. Imprted-1 Indigenous-2 Cost/ Original Value Rs. in '000 1. 2. 3. 4. 5. 6. 7. 8. 9. 10
