LOAN APPLICATION FORM PRADHAN MANTRI MUDRE YOJANA ( PMMY ) ( To be submitted along with documents as per the check list ) A.

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LOAN APPLICATION FORM PRADHAN MANTRI MUDRE YOJANA ( PMMY ) ( To be submitted along with documents as per the check list ) A. For office Use: EnterpriseName Application Sl. No.

Ltd. Company Any Others (specify) Current Business State PIN Code Business Premises Rented Owned Telephone No. Mobile No.

1 LOAN APPLICATION FORM PRADHAN MANTRI MUDRE YOJANA ( PMMY ) ( To be submitted along with documents as per the check list ) A. For office Use: EnterpriseName Application Sl. No. Name of the Branch Category Kishor / Tarun B.Business Information: Name of the Enterprise Constitution Proprietary Partnership Pvt. Ltd. Ltd. Company Any Others (specify) Current Business State PIN Code Business Premises Rented Owned Telephone No. Mobile No Business Activity Existing Proposed Date of Commencement(DD/MM/YYYY) Whether the Unit is Registered Yes No If Registered (Please mention:registration no. And the Act under which registered ) Registered office Social Category SC ST OBC Minority Community If Minority Community Buddhists Muslims Christians Sikhs Jains Zoroastrians C.Background Information of Proprietor/ Partners/ Directors: S.No Name Date of Birth Sex Residential with Mobile No. Academic Qualification Experience in the line of activity (Years)

2 S.No Id proof Id proof no. proof proof no. PAN Card/DIN No D. Names of Associate Concerns and Nature of Association: Relationship with the officials/ Director of the bank if any Names of Associate Concern of Associate Concern Presently Banking with Nature of Association Concern Extent of Interest as a Prop./Partner/ Director or Just Investor in Associate Concern E. Banking/Credit Facilities Existing: (In Rs.) Type of Facilities Presently Banking with Limit Availed Outstanding As on Security lodged Asset classification status Savings Account N. A. N. A. Current Account N. A. N. A. Cash Credit Term Loan LC/BG If banking with this bank, customer ID to be given here: It is certified that our unit has not availed any loan from any other Bank / Financial Institution in the past and I/we am/are not indebted to any other Bank / Financial Institution other than those mentioned in column no. E above. F. Credit Facilities Proposed:(In Rs.) Type of Facilities Cash Credit Term Loan LC/BG Total Amount Purpose for which Required Details of Primary Security Offered (with approx. value to be mentioned) G.In case of Working Capital: Basis of CashCredit Limit applied:(in Rs.) Actual Sales Projected

3 FY- FY- Sales Workin g Cycle in Months Inventor y Debtors Creditor s Promoter s Contributi on Limits H. In case of Term loan requirements, the details of machinery/equipment may be given as under: Type of machine / Equipment Purpose for which required Name of Supplier Total Cost of Machine Contribution being made by the promoters(rs.) Loan Required (Rs.) Total Repayment period with Moratorium period requested for I. Past Performance / Future Estimates: (In Rs.) Past Performance / Future Estimates (Actual performance for two previous years, estimates for current year and projections for next year to be provided for working capital facilities. However for term loan facilities projections to be provided till the proposed year of repayment of loan) Net Sales Net Profit Capital (Net Worth in case of Companies) Past Year-II (Actual) Past Year-I (Actual) Present Year (Estimate) Next Year (Projection) J. Status Regarding Statutory Obligations:

4 Statutory Obligations 1. Registration under Shops and Establishment Act 2. Registration under MSME (Provisional /Final) 3. Drug License 4. Latest Sales Tax Return Filed 5.Latest Income Tax Returns Filed 6.Any other Statutory dues remaining outstanding Whether Complied with (select Yes/No) If not applicable then select N. A. Remarks (Any details in connection withthe relevant obligation to be given ) K. Declaration: I/We hereby certify that all information furnished by me/us is true, correct and complete. I/We have no borrowing arrangements for the unit except as indicated in the application form. There is/are no overdue / statutory dueowed by me/us. I/We shall furnish all other information that may be required by Bank in connection with my/our application. The information may also be exchanged by you with any agency you may deem fit. You, your representatives or Reserve Bank of India or Mudra Ltd., or any other agency as authorised by you, may at any time, inspect/ verify my/our assets, books of accounts etc. in our factory/business premises as given above. You may take appropriate safeguards/action for recovery of bank s dues. Space for Photo Space for Photo Space for Photo (Signatures of Proprietor/partner/ director whose photo is affixed above) Date: Place:

5 आवव दन सस./Applicati on No. ददननसक/ Date: फय टय /Photo (फय टय पर हस तध क षर करक म ) (Signature across photo) पपरधध नमम तपरर ममदपरध यय जनध (पर एमएमवध य) कक अम तरर गत ऋण कक लल ए आवक दन पतपर Application Form for Loan under Pradhan Mantri Mudra Yojana (PMMY) (लश श म कक अम तरर गत र.50000/- तक कक ऋण कक लल ए) (For Loan upto Rs.50000/- under Shishu) बम क व श ध खध कध नध म जहध म सक ऋण लल यध जध नध हब Name of Bank & Branch from where Loan is required म, कव दल ए एतद द वनरन र. कव नकद सनख/ ओवरडडरनफ ट/ सनवदध ऋण कव दल ए आवव दन करतन हहस. I hereby apply for Cash Credit/ Over Draft/ Term Loan of Rs. for आवव दक/ककस कन/कव ननम Name of Father s/ Husband s 1. शडरर/Sh. 2. शडरर/Sh. Applicant(s) Name ससघटन वव यदकतक ससययक त Joint स वनदमत व Proprietor भनगरदनरर अन य Constitution ( ) Individual Partnership Other आवनसरय पतन Residential दकरनए पर/स वत व Rented/Owned व यनवसनदयक पतन Business दकरनए पर/स वत व Rented/Owned जन मदतदथ Date of आयय Age दल सगग पयर ष/स तडरर Birth शव क षदणक यकग यतन Education Qualification ( ) कव वनईसर दस तनवव ज Document(s) पहचनन सनक ष य (उल ल व ख करस ) Proof (pl. specify) पतन सनक ष य (उल ल व ख करस ) KYC ID अदशदक षत Illiterate 10 वरस तक Upto 10th 12 वरस तक 12th वकटर पहचनन पतडर सस. आध नर सस. Voter ID No. Aadhaar No. स ननतक Graduate डडरनइदवसग ल नइसस स Driving License No. Proof (pl. specify) टव ल रफकन सस./Telephone No. : मकबन.सस./Mobile No. : ई-मव ल / व यनवसनदयक गदतदवदध कन पडरकनर (पडरस तनदवत) Line of Business Sex : Male/Female व यनवसनदयक अन य Professional Others अन य ककई others दवद यमनन Existing अवदध Period पडरस तनदवत Proposed Any

6 Activity (Purpose) वनदषर ष क दबकड रर (ल नख र.) Annual Sales (Rs. in lakh) अनयभव, यदद हक/Experience, if any सनमनदजक शडरव णर ( दचदन हत करस ) Social Category (Pls. tick ) यदद अल प ससख यक If बब द Minority ( ) Buddhists आवश यक ऋण Loan दवद यमननग Existing : पडरस तनदवतग Proposed: मयदस ल म Muslims सनमनन य General अजन SC ईसनई Christians सरसर/ओडर - CC/OD- Amount Required र./Rs. दवद यमनन खनतन/तकस, कन दववरण, यदद हकस Detail पडरकनर (कक पयन दचदन हत करस ) of Existing Account(s), if any खनतन सस. A/c. (Pls. tick ) (जमन/ऋण)/ (Deposit/Loan) यदद ऋण खनतन हव तक ल र गई ऋण रनदश अजजन ST दसख Sikhs Type अदपव OBC जव न Jains अल प ससख यक Community पनरसर Zoroastrians सनवदध ऋण/Term Loan र./Rs. बमक व शनखन कन ननम Name of Bank & Branch If Loan A/c. Minority अन य Others No. amount of Loan taken :: 2 :: घय षणध /Declaration: म/हम घकषणन करतन हहस/ करतव हम दक मव रव / हमनरव दनरन दर गई समस त सहचननएस सत य, सहर एवस ससपहणर ष हम. मव रर/हमनरर इकनई कव दल ए आवव दन पतडर मस दकए गए उल ल व ख कव अल नवन ककई ऋण व यवस थ न नहरस हव. मनव /हमनव दकसर अन य बमक मस आवव दन नहरस दकयन हव. मव रव /हमनरव दनरन ध नदरत ककई अदतदव य/सनसदवदध क दव य नहरस हव /हम. म/हम मव रव /हमनरव आवव दन सव ससबसदध त जननकनरर बमक दनरन मनसगव जननव पर उपल ब ध करनउसगन/करनएसगव. यव सहचननएस आवश यक समझव जननव पर आप दकसर भर ससस थ न सव दवदनमय/सनझन कर सकस गव. आप, आपकव पडरदतदनदध, भनरतरय दरज वर ष बमक अथ वन मयदडरन दल. अथ वन आप दनरन पडरनदध कक त ककई भर ससस थ न दकसर भर समय ऊपर ददए पतव पर मव रर फव क टडरर/व यनवसनदयक पदरसर मस मव रर/हमनरर आदस तयकस, ल व खन बदहयकस कन दनररक षण/सत यनपन कर सकतव हम. आप बमक कर दव यतनओस कर वसहल र/सयरक षन कव दल ए समयदचत कनरर ष वनई कर सकतव हम. I/We hereby certify that all information furnished by me/us is true, correct and complete. I/We have no borrowing arrangements for the unit except as indicated in the application form. I/We have not applied to any Bank. There is/are no overdue/statutory due owed by me/us. I/We shall furnish all other information that may be required by Bank in connection with my/our application. The information may also be exchanged by you with any agency you may deem fit. You, your representative or Reserve Bank of India of MUDRA Ltd., or any other agency as authorized by you, may at any time, inspect/verify my/our assets, books of accounts etc. in our factory/business premises as given above. You may take appropriate safeguards/action for recovery of bank s dues. र/Rs. ददननसक/Date: स थ नन/Place: आवक दक/कय म कक हस तध क षर/अम रगठध Thumb Impression/Signature of Applicants (s) (कनयनर ष ल य उपयकग कव दल ए/For Office use only) पनवतर दस ल प सस... ऋण आवव दन सस. ददननसक पडरनप तकतनर ष Acknowledgement Slip No..loan Application No. dated Received by स थध न एवम लदनध म क पपरध लधकक त हस तध क षरर (श ध खध कर ममहर एवम हस तध क षर) Place and Date Authorized Signatory (Branch Seal and sign) यहनस सव कनटस /Cut here

7 शडरर/सयशडरर सव र. कव दल ए ऋण आवव दन ददननसक परएमएमवनई कव असतगर ष त आवव दन पनवतर दस ल प सस. Acknowledgement slip no. for loan application under PMMY (Applicants copy) Received with thanks from Sh./Smt. loan application dated of Rs. स थध न एवम लदनध म क : Place and Date : पपरध लधकक त हस तध क षरर (श ध खध कर ममहर एवम हस तध क षर) Authorized Signatory (Branch Seal and sign)

A. For office Use: EnterpriseName Application Sl. No. Name of the Branch Category SC/ST/Woman

Name of the Branch:. A. For office Use: EnterpriseName Application Sl. No. Name of the Branch Category SC/ST/Woman B. Business Information: Name of the Applicant / Enterprise Sol Id. APPLICATION FORM FOR