Government of Karnataka

Directorate of Industries and Commerce

Application form for Permanent Registration as Small Scale Industry


1. Provisional Registration No. :
                                 

2. Date of Issue :
           

3. Date of Commencement of Production :
           

4. Name of unit / Applicant :
                                       
                                       
                                       

5. Address for communication
                                               
                                               
                                               

Telephone:
             

Pin:

 

          

6. Category of unit

 SSI-1 ACN-2 SSSBE-3
Tiny-4 EOU-5 NON SIDO-09
 

7. Unit Location:

Place : Town
                             

Taluk : Tehsil
                             

District
                             

State
                             

8. Area of Location

 Rural-1 Urban-2 Metropoliton-3

9. Type of Organisation
Proprietory-1 Partnership-2 Pvt. 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 of to be furnished in appendix 'A')

a)

 Name :
                                           
Code :
                   

b)

 Name :
                                           
Code :
                   

c)

 Name :
                                           
Code :
                   
d) Name :
                                           
Code :
                   

e)

 Name :
                                           
Code :
                   

12. Investment in fixed assets (Rs. in 000's)

a)

 Land :
             

b)

 Building :
             

c)

 Plant and Machinery :
             

d)

 Other fixed assets :
             
Total

13. Investment in Pland and Machinery
     (Original Value in Rs. 000's)
               

(Details to be furnished in appendix - 'B')

14. Raw Materials requirement :

Name

 Item Code Imported-1 Indigenous-2

Annual Consumption (Value Rs. in 000's)

1)
               
 
           

2)
               
 
           

3)
               
 
           

4)
               
 
           

5) Other Raw Material
               

Total (1) to (5)
             

15. Source of Power

Coal - 01

 Oil - 02 LPG - 04 Electricity - 08
   

Non-Conventional energy - 16

 Traditional Energy / Fire Wood - 32

16. Power Land (1 HP= 0.795 KW)

 HP  /  KW
       

17. Employment

a) Managerial & Office Staff
     

b) Supervisory and Workers
     

c) Male
     

d) Female
     

18. Whether registered under factories Act

 yes-1 No-2
 

19. Applicant's profile

Male-1

Female -1
 

S.C. - 1

S.T. - 2
 

B.C. - 3

Others - 4

Engg. Graduate - 1

Others Graduate - 2

Others - 3
 

20. K.S.T / C.S.T
                           
                           

Signature of the Applicant

Date:
           

Name of the Proprietor / Partner / Mg. Director.

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for office use only

Application No.
           

Nic Code :
       

Block Code:
   
District 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 25-07-91 if the unit employs less than 50/100)



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