Ref - No.

1/2012-13/EE-ST
All IP rights (trademark, copyright and others) in respect of Lighting a Billion Lives rest with !"I
Sources of the above stock inventory investment Amount
Cash investment
Loan from a bank / MFI
Loan from family / relatives
Any other (specify)
Insurance Policy etails
!ype of policy (Please !ick) Policy amount "ali# till
Life insurance Policy
Shop Insurance Policy
$isk Insurance Policy
Any other (specify)
Any other (specify)
%rief #escription of e&istin' business / employment(

)&istin' business turn*over (annual+ in I,$)(
uration of e&istin' business (months)(
Appro&imate number of customers serve# in the last year(
Current area of operation (Please specify re'ions/states/#istricts)(
Preferre# area for startin' the )ner'y )nterprise (Please specify re'ions/states/#istricts)(*
etails of the e&istin' shop (if available)
-hether o.ne# or rente#(
Location / a##ress of the shop(
Appro&imate area of the shop(
Pro#ucts / services offere#(
Ma/or bran#s stocke#(
Ref - No.1/2012-13/EE-ST
Si'nature of the applicant
List of Mandatory Annexures
Please provide the following doc!ents along with the Eo" for!
1. #ast three !onths$ %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. Till a PMU is functional the details of the state in!char"e ha#e to
$e added here $efore sendin" 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+ 'ovt0 officials+ eminent citi1ens)
At least t&o references are mandatory. The 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-