Ref - No.

1/2012-13/EE-ST
Expression of Interest Form for setting up Energy Enterprise
All IP rights (trademark, copyright and others) in respect of Lighting a Billion Lives rest with !"I
Ref - No.1/2012-13/EE-ST
All IP rights (trademark, copyright and others) in respect of Lighting a Billion Lives rest with !"I
Note: All fields are mandatory. To be filled completely. Incomplete forms would not be considered for the
selection process
Name of the Applicant:
Name of the proposed enterprise:
Address of the Applicant / Enterprise:
(Please provide details below)
Country State
istrict !loc"
Pin Code
#el nos$ %a& Nos$ Email:
Current occupation:
Name of the or'ani(ation affiliated to) if any*
Address of the or'ani(ation:
#el No$: +obile No$: Email:
#ype of the or'ani(ation affiliated to) if any (Please #ic")
Non ,overnmental -r'ani(ation
#rust/Civil Society/Self .elp ,roup
#E/0 #echnolo'ies 1imited
Common Service Centre/ Primary A'riculture Co2operatives
/e'ional /ural !an"/+icro %inance 0nstitution
1ocal ,overnment
-thers (specify)
PAN No$of the applicant:
!an" Account No:
Name of the !an":
#0N No$of the applicant (if available):
C0!01 #rans3nion Score (if available) of financial worthiness
(ran'e: 455 to 655):
Assets owned by the applicant in his / her name:
(car) scooter) house etc$)
+a7or (current) source of income of the applicant (Please #ic") and 'ive details in the empty space
Shop
Salaried employment
!usiness (retail)
!usiness (service)
No income
-thers (specify)
Actual / Proposed stoc" inventory investment value (in 0N/):
Sources of the above stoc" inventory investment Amount
Cash investment
1oan from a ban" / +%0
1oan from family / relatives
Any other (specify)
0nsurance Policy etails
#ype of policy (Please #ic") Policy amount 8alid till
1ife insurance Policy
Shop 0nsurance Policy
/is" 0nsurance Policy
Any other (specify)
Ref - No.1/2012-13/EE-ST
Si'nature of the applicant
List of Mandatory Annexures
Please provide the following doc!ents along with the Eo" for!
1. #ast three !onths$ %an& accont state!ent for the accont !entioned a%ove in the for!.
2. 'ertificate of credit worthiness fro! the #ead (an& of the respective district.
3. 'ertificate fro! a local police station of not having an) cri!inal record or notarised affidavit on self-declaration of no
past cri!inal records
*. (alance sheet of the e+isting %siness for last one )ear
Send EOI to: (each PMU to add this information !i"" a PMU is functiona"# the detai"s of the state in$charge ha%e to
&e added here &efore sending the form to an EE'
,ddress- address of the P./
E!ail- e!ail of the P./ /contact person of respective P./
All IP rights (trademark, copyright and others) in respect of Lighting a Billion Lives rest with !"I
"eferences ( from school/colle'e/university faculty) panchayat member) 'ovt$ officials) eminent citi(ens)
At "east t(o references are mandatory !he references ha%e to &e from the same district
Na!e of the referee-
0ccpation with designation-
,ddress-
'ontact no-
Na!e of the referee-
0ccpation with designation-
,ddress-
'ontact no-
Na!e of the referee-
0ccpation with designation-
,ddress-
'ontact no-