16

No.
COMMON APPLICATION FORM I
PART A
FOR ESTABLISHMENT
This format is to be filed with the Nodal Agency for the purpose of arranging site clearance, statutory
approvals
from Gram Panchayat, Municipality, TC & P, Urban Development Authority, Factories, Alienation of land
/ Acquisition
of land, Power feasibility and Power connection from DISCOM, sanction of water supply from local
bodies / HMWS &
SB / Ground water for setting up of industrial units in A.P.
(Please go through instructions carefully to fill in this form given separately)
(Please submit required number of copies as per check slip including one for your record)
1.1 NAME & ADDRESS OF THE PROMOTER/INDUSTRIAL UNDERTAKING IN FULL (BLOCK LETTERS)
Name of the Industrial Undertaking:
Name of the Promoter/M.D./Mg. Partner with surname first
Shri/Smt./Kum. (Please strike off those not applicable)
S/o./D/o./W/o.
Age Occupation
1.2 ADDRESS FOR COMMUNICATION
Door No. Street Name Village/Town
Mandal District Pin Code
E-mail Fax Telephone (incl. STD code)
2. Nature of Organisation: (Please Tick)
Proprietary Partnership Private Limited
Public Ltd. Co-Operative Others
3. For Proprietary Units Only. Do you belong to : (Please Tick)
SC ST OBC Women
17
4.0 Registration Particulars
4.1 Category of Registration Prov.SSI IEM EOU LOI
(Pl tick whichever is applicable)
DM Y
4.2 Registration No. and Date
DM Y
4.3 Expiry Date
5.1 Line of manufacture:
Sl.No Item Description Annual Installed Capacity
Units Quantity
5.2. Raw - materials used in process
Sl.No Name of the Raw Material Annual Requirement
Units Quantity
5.3. Details of Plant & Machinery (Pl. enclose list)
5.4. Brief description of manufacturing process : (Pl. enclose separate sheet)
5.5. Does your unit fall under the category of Yes No
65 polluting industries
5.6. Type and Nature of wastes and effluents their
Quantities and the methods of their disposal
(Enclose Separate Sheet)
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6.0. Estimated Project Cost. New Unit Substantial Expansion
6.1 Land (in Rs.)
6.2 Building (in Rs.)
6.3 Plant and Machinery (in Rs.)
6.4. Total cost of (6.1 + 6.2+6.3) (in Rs.)
7.0. Probable Employment Potential :
(In No. of persons to be employed) Male Female
7.1. Direct (On units payroll) :
7.2. Indirect (On factory premises) :
8.0. Details of existing Approvals of Factories dept
Gram Panchayat / Municipality / Electricity / Water, if any D M Y
Reference No. Date :
9.0 Proposed location of the factory : IE IDA EZ PE others
9.1 Location/Name of IE/IDA/EZ/PE
9.2 Survey No Extent Sq.Mts
Street Name Village/Town
Mandal District
Pin code Tele Phone No
Nearest Tele Phone No.
10. Power required for the unit
10.1. Contracted Maximum demand in KVA
10.2. Connected load in KW
10.3. Aggregate installed capacity of the transformer to be installed by
the entrepreneur in case of H.T. (H.T. means above 150 H.P.)
Per day Per month
10.4. Proposed maximum working hours
19
MY
10.5. Expected month and year of trial production
DM Y
10.6. Probable date of requirement of power supply.
11.1. Water Supply from Gram Panchayat Municipality HMWS & SB APIIC
(Pl. tick relevant agency)
11.2. Water requirement Quantity (in KL / Day)
i) Drinking Water
ii) Water for Processing (Industrial Use)
11.3. Size of Water Supply connection applied for
15mm 20mm 25mm 40mm 50mm
(1/2) (3/4) (1) (1) (2)
If the size is not covered in the above mentioned sizes, indicate the size of connection required
11.4. Size of sewer connection applied for
100mm 150mm 200mm
(4) (6) (8)
12.0 Permission to draw water
12.1. Agency Ground Water Irrigation
12.2. Requirement of Water Quantity (in KL / Day)
I declare that the particulars given above are true to the best of my knowledge and belief. I shall obey
the
rules and regulations in force. If any deviation is found, suitable action may be initiated.
Place :
Date :
Signature of Promoter or
authorised person only in Ink
NAME (IN BLOCK LETTERS)
(DESIGNATION)