onlineapp_allotplotshed

7/27/2019 onlineapp_allotplotshed

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tmo'!"C> ~~n I N~~~N' ~o'(;.3!mf\ ~~~Application for Allotment of Industrial Shed I Plot

DODDa) Name of the Applicant (s) in Block L~ters I~Fr:J;)o'~ (0') ~;tjQ) d~50'Ti9t!)OJ.. ""b) Male / Female Tio~ I ~~ ;rn Ic) Name of Father / Husband

30doi) I TiozZ~~;tjQ)0

2 a) Type of Shed/Plot Applied for~~F ;j~",t:S ~~~ I ~~~~~ ~t:So

b) Number of Sheds/Plot Applied for~~F ;j~.!Jt:S~~~ I ~~~~~ ;jO~6ri~

c) Industrial Estate at which appliedQD;)~ ~o~ ~~~;3;)~~~ ?j~~,,~

d) Why this location is chosen & LocationalAdvantages?...~~ ;j9~~~ w~ t.)oj.);;;~,,~ ~;3;) ;j~~oj.)'" ~ ...'"~~M~rito'~~ ?

DOODD

-3 ADDRESS / ~'o';)~a) Registered Office~O~~35d~O J

b} Factory (if existing)I~f"~ (~~o.:1,)J~rt,d) c) For correspondence!~6~~dUC)~1'\ i

!

4. Mark the category to which the applicant belongs (tI') ~~F~ddJ c.DCJ;Soo.!J~~eoQ)~oo~~ roQ)~~oO ~~~ (tI').(1) SC D (5) Technocrat D (1) ~.~ D (5) 30~~ D

(2) ST D (6) Women EnterprenuerD (2) ~.~o 0 (6) ~oo~ wd6~ 0(3) Ex -serviceman D (7) Minority D (3) ~~~ ~.fJ5 D (7) ~~ ~O~63 0(4) NRI D (8) General (Other) 0 (4) ~~wc).!J~d~ecj.) 0 (8) ~~~ (~3d) D

~ K 5511) (: (5~F~5 ~Fdoeroo6~) KSSIDCO OpKarnataka State Small Industries Development Corporatio-" Ltd.

(A Government of Karnataka Concern)


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2Whether the applicant earlier worked in any Govt. organisation / quasi Govt. organisation / reputed companies.~~Fo;Jd~ ~ ~o~ ~~FC I ~" ~~FC I ~~~Q;3;)~ o~Qi) erot;S.fC).~/'\om/'\~"a1J~?";:)~dM~.'" " GO

Salary drawno:j~o:$.))~t:Se~~~QName of organisation

;;::?~o:$.) .~~O.:>,Designation~t:5GO

Industrial Estate Name Shed/Plot No. alloted~OC;) ~~~;3;)~~ ~;;:jd) ~o?d~oD;,O~~~/N~e!!~o ;;:jO~6

DDD DDIf you are already alloted with shed / plot in Govt.India Estate Please give particulars.No;i)~~ ~ode ~~Fd t~O5C) j~~3.?~~~ o;i)~~1N~e!!~~o2.!~o,ij;)"~d;jd1iQ~ M~.a) Number & Date of SSI Registration Certificate

.:>~ ..:>~ .0:). oSJO>eoo~~o ;;;jo~6 :i)~ O~o5b) Provisionally or Permanently issued

3;)3;)c()5~ ~~~ :;j";)c:SJo1'\ OJe~~1'\~ai:)e?

7-

Products proposed to be manufactured / beingmanufactured;3QDC)o6~ ero~~!>~Q);S I ;3QDC)~ro~ti);S ero~~r19J

a) Constitution: Please Mark;!:jo::JQO)~ : ~d?:5~ ~~. (.I)(.I)

(1) Proprietorship D (1) ~!)5~ D(2) Partnership D (2) ~WCi)O~ D(3) Pvt. Ltd. Co. D (3) :;j"i)~1'\@::JJ;3 o~ D(4) Public Ltd. Co. D (4) ~~F"...,~5~@::JJ;3 o~D(5) HUF D (5) z.,ot;i")Q;)~""6~~o~ D(6) Co-op. Soci (6) ~~'6'i)O oopl

b) Details of Proprietor / Partners / Directors ~!)e5d I ~WCi)dd I ~~F"e~5dQ;)~dnr.i..1~irth Place

lII:$~;;:if."e.-Cj)Age

~ci);!:jJ'"51.No.~. ;;:Jo. Name~';:Q) Qualification Ia5F"~Da~e of I Domicile Sh~re

Birth ~;r::;r::e.'! holdingQ~~e, O~O6 1 ' ~oOdJ0;5.~~dJT1e.'! 0:)0;50


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3c) Name of the Managing Partners / Director /

Chief Executive~6~~Q;j5 Q;jC)~~d~ I ~6~~Q;j5 ~dF"~~5~~~6~~F~5d ~~~

Particulars of Machinery -Indigeneous / imported c:1.?o~e~5d~KeJ ;;:Jo:SdKeoiJebec:1.? e~C"i)dd;?,Date ofAcqun.o::j~~MOt3~O~:i);)

ExpectedDelry. Dated~~Qi)

~ot:jC)~ ON"JO~.

Imported/l n d i e n e o u

~~t;j;)t'I~ ~~h~oDName ofDespn

05~O:J ~;3;)...~~~6

New / Sechand~;:jdJl~r.'~dJ

Name ofMfrer.~omd5d~~d:)

TotalCost2...~~51.No.,;.;;:jo.

Imp.L.ref.e~d~f'Ierode~M

5~ m~a,~foi ~~36~foiJ1. Raw Materials RequirementsAnnualRequire-ments~. ~T1;!6

Name of theSupplier;;:. oS;;:dJ

Price ! quota price!open market price~~ ~~5~ ?,j~Free availa1ility/quota~~6~Me~

Name of RawMaterials5.m. ~;;:Jd)

Remarks~CC)

51.No.~.~o.Indigenous 1mported I

rj~. II

~~1\~i Q;

12. POWER: Furnish details of powerrequirements in K.W.:J~6;s6' : :J~6;s6'~r1:!6r1~~ 6~~~6~r1~~ ~~.!J.

13. WATER: Furnish details of water requirments inLiters.~~d) : ~~o~ ~~:!o~~ t!)~~c6'~";~ ~


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414. MANPOWER: Furnish details of manpower requirments in Nos.

~o":S~6 ~~;;:j7'l;)dd ~Ti3,Titoc!/.J~ ;;:jo~,~() ~(>,t,...,,() " MSkilled/Semi-skilled/Un-skilled

~O~~dJ I ~~~O~~dJ I~o~~d~o~dJAdministrative

~~;$ ~r1FO~d:JTechnical

~O~5~~FO~~Totalt..~

Amount alreadyspent~?3:JF~~o i:5ro

Amount proposed to .be spenteroti,~!>;!~F I

15. MEANS OF FINANCE: (As. in Lakhs)cEr'O)5'O);;:'.)~ (dJ't). ~tK~~ Totalt..~1) Own Funds~o~ '/.)otZ~~2) Capital promoters'/.)otZ~~ ~e~~5ti)3) Internal accruals

~~ ;;:io~a:SJ~nfo1J4) Term Loans~~~ N;)~nfo1J5) Govt. Subsidies

;;:i~FO ;;:ia3'O)a:SJ ;:I~6) Other Sources",~t5 ~~nfo1J

16. PROJECT COST ~et;$~ ~?1~Turn over~&o~~

Total cost of Project~~~~OiJ t...~ ~'I..1:>F"

Provision for instalment of shedI~~ 503.1Q;j&)~~m1'l ~C;)!!

Profit~Q


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5MARKETING: Please indicate the details of effortsmade for marketing the products by marking (v)~CC)~ : ero~~nfo-l~ ~CC)~ ~r3~ ~M~~~o.1,)~nfo-l::J~d rud)~.!J (v)

a) Tie-up with export companyd~ ;;:jo~~oO~ ;;:j~~~T1=- Qb) Registration with DGS & D

~.~.o;);1:j6'. ;!) ~ ~() ~~orj~-' Mc) KSIMC ~.o;);1:j6'Q:).o;)~ ~.d) Stores Purchase Department ';;:jd~ :i)O~O ~~~e) State Trading Corporation

~~~ ~~~one 'O'i)*Fd~~N6'f) Apparel Export Promotion Council~Q;jd~ O;)~~~~F ~~~~N6' ~%~g) ET & TDC ~.~. ~~ ~.~.~.h) Leather Goods Export Promotion Council

~rjO6' T1.I;>~ %~i) Others please specify ~;3d :Jojd M~.

Please indicate whether your proposed unit comes under any of the items specified by marking (tI)against the appropriate type~~e, ero~eh;3opI~5~ ~e.iF\~ i1'CJ~'l)o:;~ ~edJ~~ wo~~~ (tI) f'I)~~~ ~~5 ;tJ;)eo.!J1) Electronics especially import substitution items.

::J~e~Q;J'O)F\~ ~~r1e.i ~~~F\ wd~~~ ero~6~.2) Technically sophisticated items including new process/designs/products indigenously developed new

lince of products in the country.~~ ;;:OMe~;3 ~~r1~ ~eo ~d;3~~o:11e e~~o", ~[:3.!J~ ero~~ ;30~t3;)~ ~oo~ ero~~r1e.iJ.

3) Export-oriented units 50% minimum export obligation.d~ e'Q;)O;3opI~5r1e.iJ~e. 50 5~~ d~

4) Pharmaceutical and pesticides with preference for import substitution.~~~r1~~ ;;:O;!O;)f..3oi1'CJf'I)~~r1~~ ~~6~~OO~ ~~Q 030>M~;:;:;~~5r1e.iJ.

5) Chemicals-Final consumer items, Chemicals-industrial raw materials preference being given to importsubstitution items.~~~r1~~ ;;:O;!O;)f..3oi1'CJf'I)~~r1~~ ~~6~~OO~ ~~dJ ~e.i~~dd o;);!O;)~~5r1e.iJ~dJ I tmc;, 5~ ;!O;)~a..

6) Light Engineering consumer products including components.~[:3 ~r1r1~ ~eo ~f'I)d o2f,~~OOn6' ~e.i~OC)dd ro;3~r1e.iJ."'0(

7) Leather and Leather based units.~~F ~:5:? ~QCJO;3ro~6~r1e.iJ.8) Food based Industries~d ~O;3 ero~6~r1e.iJ.

19) If yours is a chemical or other pollution prone industry Iplease indicate proposed arrangement to disposetreatement of effluents PL. indicate PCB Licence ref.N~P;; O;)~o.1J0;)5~tPQ;Jt) ~~{,~d tmo~om1'l~~~~~{,~o.1J~ ,;:O~O,;:~ I Mt;!l:i)w;)5~ ~o~ ~{,~~TitoiZJ~ ~~O.!J .!J.!J~ orJdQ;Jt)~1'I;:o:j o.1J~ ~~.!J\. {, " .

20) Earliest probable period of time after allotment of shedby which applicant can start production.


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Other Assets;3~ ~.tJr1fo1JJ

Personal Liability~o;td 2.jC)Q6~71~

Immovables covering details likeland and building2;$;;:;::;~~~ 5~~nr.-!O;5i$

~Qjdnr.-!~r.-!MO~ J,CC)":.n~Address:Je.';);;:j

Location~9'"Date of Acqn.MOtZ ON;)O~-Cost~~Present Value~;;:j5~~...~

Are you alan IT/WT assessee? If so please furnishdetails of Tax paid for past three years.~~~ f:5CC)o:i:);3.) f:5~ $O~CC)dO;)l'IdJ~O;)? WCJl'ld!J5r.'dQM~dJ ~~F"7ito"!J Q:J;)~~~~d $O~o:i:) ~~d ~~~.MTwo references of respectable well placed personswith address and telephone No.OJ;;l)e,;:!o~aiI;;)dJ~ ~dJ n('Q)6 ;,T1.r&>';~;3 ~6~ne.'! ;)~;tjw;,T1.r&>;ilC)d~ro ;tjO~6 .;r:~.Particulars of payment of EMD/application fee.~oK~ ~e~~ ~E'Q)/~~F" e.>c ;j;)~'; ~t30 .:J~dK~. Amount Receipt No.~'I.)~ru d.!Je~ ;rjO~6

=:JDDDD D DDDDDateo~o~

000000Code No.

~O~~;$ ~O~6ODDSC/ST

Q;3.~.1Q;3.Q;30.GENERAL

;!~

As. 25-00 + Tax ~o~ 50-00 + Tax ~o~As. 50-00 As. 200-00

As. 500-00 As. 500-00

a) Payment of Application Fee (Non-refundable)~dJQ;J;)~~QD;)nd~*C~ ~~F" ~~1I

b) Payment of Scrutiny fee (non-refundable)~dJ;!J;>~~QD;)nd ~o!>~~~ ~~1I

c) Payment of EMD.~on1Z ~~~~~ Q;J;)~~

d) Sheds in Industrial Estate not covered underBangalore agglomeration area (covered byDLAC) refundable.tjon'o1J;)d,)o~ ~~~ ~~dd~o~ ~~~~


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7(A type shed) .:) ~oo ~~~

4000-00 ~ ~do ~~~~ ~do ~.;J~

ed) ~ ~dO ~"

Documents to be submitted in duplicate~~~c:$,:)~ ;;::~;;::~~e;)~ ~~~r1~

ii. Sheds in Industrial Estate covered under Bangalore 2500-00 5000-00agg lomeration area (covered by SLAC ) refundable. 2000-00, ,~?"5o71~o:>~o~ ~~ci1~ ~eoo ~o~ ~AjC)CX:~:J~~~(J~71C)rI(O';Jt;$ ~o CX:o~~ ;:!:JJ~ci1 ~ lJ~ 'Z.)0:>~0,)) 1500-00~ w ~...~0:>~~~oD&1T\)~O3~. 1000-00

e) Payment of Electricity Deposit__:J0,)6~ ~~~~ ~~~ I'

(Note: Crossed D.D. drawn in favour of KSSIDC Ltd payable at Bangalore be submitted)~~~ : ~.~;tj6" ~;tj6" ~.~..!I. ():JJ~r;36' o:!d~rI ?"5o71~O~1!;!, ~~oD&1T\)~ ~.~. ~~5 t..~?"5~~.

25. Particulars of submission of application Notification reference and date:~~F" ;;:!1!;!,~ci1J~d71~ ~5~~ci1 w~~~ ~~ ON;)o5

Date of issue of application:~~F" o:!~o')Mor3 O~o5Date of submission of application:~~F" ;;:!().!IO ON;)o5

1) Application form ~~F" '"tJddo.2~ Provisional/permanent SSI Certificate issued by or P&C

OJ~F"~~50:>. ~ OJ~~o ~~o()5/:;jOIci1o SS I ~~oo~ o:!~3) Detailed project report comprising cash-flow

performance projection profitability & provision towardsrepayment of shed cost.~710,) ~~~ w~~b3 ~oD&1F"zjd~, ~Qb~~~ ~;!) ~(J~.Q ...?"5~~d:>~~~ ~~~!!719~9MOr3 :J~d~o ~~t;$~ ~do

4) Approval from state level Committee or Department ofElectronics in case electronics items based production.~~~OJe6" ~~~oD&1Q"i)O3 WO6~~rI~~ 0';Jt;$6~J ;;:!:JJ~~~~ ~~~OJ~ ~~~F"~o~OJoo ~(:i)~~o~.

5) Foreign collaboration agreement if any.:J~~b ;;:!CX:~e710 t..o:!oo ~N;)od/;) ~o~.OJ Q6) An undertaking that local persons SC/ST will be gienpreference.;;:!(Jeci1/o:!.~./ o:!.o:!o. t;$~o71 oo.~ OJ~t3.)~ Z.)~ ~zj(J~.S!. ,," ..7) l,;ertificate from competent authorities in case theapplicant belongs to SC/ST Ex-serviceman/technocrat.~~F"C;)do:> o:!.~./ o:!.o:!o./ OJ~3 ~~5d:> 303,t;$O';JrlOt5~O~,3f- ~ ~ Q , u~{p~5d~ o:!~.8) Line Diagram indicating machinery Layout plan.ci1o~AjC)~~, ~o:!~ci1~ !(J;;:!.)~ ~~.

9) In case of PIS concern -P.S. deed.~~C;)O~ WO~oD&1o() ~~rIC)O~ o:!3,.""" ~10) In case of a Co-Memorandum & Articles of Assn.w~~~ 50o:!OJoD&1r19,1!;!,~O';J6r30 ~~ ~~F"5~ ~~~~.!I~e~~ .

The particulars furnished above are true and correct to the best of my belief and knowledge~~O~ :;;~dnfoiJ ~;36Q;ji)O~ Q;i)~ ~~ ~('Q)F ~o~~ w;)M :!'foiJ~()~ai> ~5;)d ~oomo~ ~"d.:>~d.

Name in Block Letters .., Signature of the Proprietor I Partner I Director~;;:O:> ~ ~~drlr.iq, ~!J~o:> I ~~~do:> I OJdF"e!!~d;:00

Note: Please note the incompleted application without required enclosures and leaving blank any ofthe colu~n is liable for rejection.


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8FOR OFFICE USE ONLY

c'~~O~ ero~~~r('50~~1) Project report sent to 8181 for feasibility report on

;;:j.t.~~. ;;:j~ ;;:jO~~6'!";) ~dOnCJ1't,~~~~~dOoi)~59Jlo.!JOO~O5.

DateO~o5 DDDDDDDDYes No~O,) ~~M

DateON;Jo5DDDDDDD2) Feasibility report received or not received?;l:jO'ljjC)~6:!C)doQ:t).) ~oOd~~ ...~~?3) Remarks of 8181 on the project report

o1IC>~tS~ dOo.1) ~~ ;I:j.t.~~.;l:jo. ~~~0.1)4) Recommendation of the interview committee

;l:joO!!F~ ;I:j~~o.1) !>~d~7i9J5) Recommendation of the interview committee~Od~F~ ~:;:;:;~OiJ~Oi:iCJd~ne.iJj

DDDDDD) Date of SAC meeting and decision~~~ ~3d~ ~;:;:;~ ~~~ ON;)O5~~ ~~~F~...7) Shed allotment -Scheme under which allotted

~~ .x:o?!~ -cD&>~ ~~~~cj.)nd?M DODDDDShed / plot type-~~~ I ~~~!!~ ~tjoDDD

Receipt No.d~~O ;!:jO~6

DateO~o5

Amount~t.)~ro

-Shed/plot number-~(>~ I N~e~o:S!:jo~"8) EMD amount to be refunded in the case of shed not

allotted~(>~ a50~~om/'o~O~~ ~dJ~~';omTi~511 o:SJi>~~ro

9) Recommendation of refund~dJ;;jC)~';~ ~~d;;;.,

10) EMD refund -Voucher No. and Date~or\~ ~~~~ ~roo ~Q;)Q:j';)~'; .';)~d~~c6' ;;;:0~6 ~~ 003;)05

-Cheque No. and Date-~C6' ;;;:0~6 ~~ 003;)05-Despatch reference-dQ:jO)~ erod~~M--


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KARNATAKA STATE SMALL INDUSTRIES DEVELOPMENT CORPN. LTD( INDUSTRIAL ESTATE, RAJAJINAGAR,BANGALORE-560 044 )

SUPPLEMENTARY APPLICATION FORM TO BE FILLEDIN PERSON IN BLOCK LETTERS BY THE APPLICANT:

I. Details on the Entrepreneur / Firm applying for theshed / plot

IS THE APPLICANT: Please tick theAppropriate column

a) a first generation entrepreneur YES NO

b) woman entrepreneur YES NO

c) belongs to SC/ST category (enclose anattested copy of the certificate issued by thecompetent authority)

YES NO

d) differently abled category (enclose an

attested copy of the certificate issued bythe competent authority) YES NO

e) an Ex-serviceman (enclose an attested copyof the certificate issued by the competentauthority)

YES NO

f) a Foreign repatriate bringing in Expertise. YES NO

If YES, provide details

g) Is the applicant an NRI

h) a local entrepreneur. (Whether residing inKarnataka for the past 5 years or more)

( enclose Domicile Certificate )

YES NO

i) technically qualified intending to startthe unit in the field of his expertise. (enclosethe relevant Degree Certificates, attestedcopies)

YES NO

j) does the applicant have any previouswork experience connected to the presentproject. (If so, enclose experience certificate)

YES NO

k) Has the applicant availed any benefit underPMRY Scheme. If so details.

YES NO

l) Has the applicant been allotted a shed /

plot in any of the Industrial Estates of KSSIDC. YES NO

If YES, details.


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m) Have any of the family members ( meanswhere the applicant is an individual, or a firm,his /her spouse, children and partners ) alreadyallotted a shed / plot OR applied for shed/plot in any of the Industrial Estates ofKSSIDC/KIADB. If not an affidavit notarized(asper the format enclosed needs to be submittedon a Rs.100/- stamp paper)

YES NO

If YES, details.

n) If the applicant has been allotted shed/plotby either KSSIDC /KIADB has the same beenfully utilized / partly utilized for the allottedindustrial purposes.

YES NO

If YES, details.

o) Has the applicant been allotted shed /plotby either KSSIDC / KIADB and havetransferred / changed the constitution of theindustrial property outside specified familymembers (that is except spouse and children)or have rented out such shed / plot.

YES NO

If YES, details.

II. PARTICULARS FOR THE PROJECT FOR WHICH THESHED / PLOT HAS BEEN APPLIED FOR ALLOTMENT (TO BEFILLLED BOTH FOR EXISTING AND NEW PROJECTS.

Rs.Rs.Rs.Rs.

1. Project details I ) Project costii) Own investmentiii) Borrowings andiv) Sources there of

TOTAL

2Constitution Proprietorship Partnership Pvt.Ltd.


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..3..

3. Productclassification Food Chemical Garments

Electrical Textile Electronics

Engineering Packaging Printing

Plastic Medical Eqip PharmaSpecify Others

4. Infrastructurerequired for theproject

iv) Covered areaiv) Open areaiv) Power requirement- H.P

iv) Monthly water requirement (Ltrs)

5. Employmentgeneration: (No.of employees inthe unit)

Skilled :Unskilled :Managerial :Male :Female :

6. OTHER DETAILS:

a) In the case of the applicant applying for sheds,is the entrepreneur willing for payment of 99 % ofshed cost upfront within 45 days of allotment. YES NO

b) Is the project report enclosed YES NO

c) Is the SSI Registration Certificate enclosed YES NO

d) Is the product an import substitution. YES NO

e) Is the product export oriented. YES NO

f) Is the project labour intensive. YES NO

g) Does the project generate effluents and airpollutants. Is there hazardous waste?.

YES NO

h) If yes, has the unit has made any provision

in the project for waste treatment beforedisposal.

YES NO

i) Whether the project is water intensive ?.Water consumption details per day.

YES NO

j) Whether the project is Power intensive. YES NO

k) Is it an ancillary to any public sector/ pvt. sectorlarge/ medium unit.

YES NO

7. Financialdetails

i) Details of Cash flow (Separate Statement tobe enclosed)

ii) Details of average Debt Service CoverageRatio (Separate Statement to be enclosed)

iii) Is the financial viability study of the projectmade by any financial institution. YES / NOIf yes, enclose report


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..4..

8. IF THE APPLICANT HAS AN EXISTING UNIT, THEFOLLOWING DETAILS TO BE PROVIDED.

I) Does the applicant have an existingunit presently running successfully inprivate premises with a need toshift from the existing location.

YES NO

ii) Detailed addresses of the presentlocation and ownership details.(Copy of Rental agreement to beenclosed if applicable.)

(iii) Details of workforce employed i) Skilledii) Unskillediii) Managerialiv) Malev) Female

(iv) Whether the unit hasany certification ISO 9001 ISO 14000 BIS

Others specify:

(v) Whether there is tie up with anyforeign promoters.

YES NO

If so, furnish details.

(vi)Whether there is tie up with any local/MNCs/ large Industries.

YES NO

If so, furnish details.

(vii) Furnish details of VAT /MODVAT / Sales TaxRegistration. (Copies tobe enclosed)

(viii) Furnish copy of the SSI Registration Certificate (PMT )(ix) Details of annual turnover with audited statement and PAN

NO./TAN NO. for the last two years be enclosed.X) Whether it is registered as an export unit or is a deemed

exporter. Details to be furnished along with the certificates.

SIGNATURE OF THE APPLICANT.

C/MYDO/CHE LIST 2


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AFFIDAVIT

I / We ------------------------------------ S/o, D/o ---------------------------------aged

about ---- years residing at No.--------------------------------------------------------

----------------------------------------------------------- do herby , solemnly declare

on oath as under:

That I / We are applying for an allotment of Shed / Plot at Industrial Estate ----

----------------- against Notification No.---------------------- dated -----------

Issued by the KARNATAKA STATE SMALL INDUSTRIES DEVEOPMENT

CORPORATION LIMITED.

Whereas, That, I / We do hereby declare that, I / We or Our family members

(Means where the applicant is individual or a firm, his or her spouse children

and partners) have not applied for allotment of Sheds / Plots for the same

notification through other application.

That, I / We hereby declare that, I / We or our family members / partners have

not been allotted sheds / plots by the KARNATAKA STATE SMALL INDUSTRIES

DEVELOPMENT CORPORATION LIMITED any where in Karnataka since 1960 at

any point of time.

That, the information declared above are true and correct to the best of my

knowledge. In case, if the above declaration is found to be false, the allotment

made in my / our favour is liable to be cancelled in addition to forfeiture of EMD

and other amounts paid by me / us to KARNATAKA STATE SMALL INDUSTRIES

DEVELOPMENT CORPORATION LIMITED.

DEPONENT

Place :

Date :

Identified by me

Advocate Sworn to before me

No. of Corrections.