lywe apply for the Facilities detailed below: Purpose of the Loan: 1. Name of the Entity: M/s 2. Registored Address of the Entity Email Address ing Address of the Entity: Landmark - Since when did operations start at this address? Has the address changed in the last 3 years C]yes ~ LINo. Earlier Address: Reason for change in address: 4. Business Premis Tl owned and encumbered Tlowned & Free C Rented 5. Name of the Contact Person: Mr/MrsiMiss Email Address if any Designation 6.Constitution: ClsoleProprietorship —-CIPartnership Loprivate tr. Dubie tra 7. Nature of Business: [] Manufacturing Lisenvice i Retail rade] Wholesale Trade For Manufacturing / Processing Units For Service Unis (Including Retail Tr Investment in Plant Machinery Please Select (V) Office Equipment (Gross Block) Please Select (7) {Gross Block) Upto Rs. 10 lakh Upto Rs. 4takh > 10 lakh and upto 25 lakh > d lakh and upto 10 1akh > 25 lakh and upto 5 crore >TO lakh and unto 2 crore > Serore > Devore “Type of Industry: Retail Trade Products deal with Wholesale Trade 1 Village Industry & Cottage Industry Vilages and small towns with population not exeeeding 50000) Dyes Cno liyanisans COYes Cno 8. Details & Unit: DNewUnit: ClYes L1Ne iy Women Operated & /or Women Owned: Ces CINo. i) ete Chief Promoter from a Minority Community: CI¥es _ INo Number of Employees: 10. Any benefits availed und: lending? —- D¥es.CNo 11. SSI Registration Number 12, Sales Tax No.V ICICI Bank (eT eral ated | khayaal aapka ens Details of existing credit facilities enjoyed by t Name of Facility ‘Sanctioned Amount (Rs.)_ Present Outstanding (Rs.)___Loan Account No. Security Offered eee ee) Name of the Entity Nature of Business Net Sales Net Profit Net Worth Nature of Facility ‘Sanctioned Amount Present Outstanding ‘Security Offered ae) 1. Promoter 2, Promoter Name: Name: Father's Name: Father's Name: “% share holding: « CD Unmarre a Qualification: Date of Birth STD Code: 1 Gredit Card No, Tel. No Credit Card No, Business Experience (Years) Res, Ad Ty owned [] Rented Years in Current Residence: TO owned [] Rented Years in Current Resi Monthy Ret i ented Rs Monthy Rent i rented: Re PAN GIR No ] PAN / GIR No Nationa Nationality Cetegery: C1 sc List Limes Close 1 ce ‘challenged Cl Retired armed forces personnel Category: C1 sc List Clas Close C1 ce physically challenged oth CMate 2 Fem: Ol Fem Gon Minority Community : Yes C] Ne]MCICI Bank (eT era lated | khayaal aapka 3. Promoter 4. Promoter Name: sus Name: Father's Name: Father's Name: % share holding: % share holding: (Marita Status: Married Cl Unmarre Marital Status: Cl Martied — C Unmarsied No, of Dependants: Qualification: No, of Dependants: Qualifestion: su Date of Birth STD Code: Date of Birth STD Code: Tel No. Tel. Neo. Credit Card No, Business Experience (Veal: warwnmen sn Business Experience (Ve Res. Add Res, Add: Owned i Rented Years in Current Residence: ama 1 owned C] Rented Years in Current Residence: ‘Monthly Rent (frente): Re. Monthly Rent (if rented): Re. PAN / GIR No: PAN / GIR No: Nationality: wm Nationality ry: CISC LIST Clmas CJoBe C1 Ge Cphysiealy challenged Cl Retired arme ; i Other: Minority Community: Yes C] Not] | Gen Category: C1 sc C1 st Limes. C)08e C1 Ge Physically chalen Other: Gon Cates 1d Retired armed forces Oi Female Minority Community : Yes [J NoC] eae Name ofLoan Promoter's Name Availed from Sanctioned amount Present Outstanding Last installment date Cnt ere 1. Name of Entity Contact Person: Designation: ‘Type of Relationship [Supplier/Customer/Competitor]: ermimnnirnnnsirnninmnninmnninn STD Code Tel. No: Mobile No: E-mail Address: Address: 2, Name of Entity: snmeneunennnnennnnsinnnsni Contact Person: Designation: ‘Type of Relationship [Supplier/Customer/Competitor} STD Code! srnesnsninnine Tel NO: E-mail Address: Address: 3, Name of Entity: Contact Person: sinminnineninninennanine ‘Type of Relationship [Supplier/Customer/Competitor] STD Code Tel. No: Mobile No: E-mail Address: . Address: 4, Name of Entity Contact Person: snmitinenaninennnnei ‘Type of Relationship [Supplier/Customer/Competitor]:verunsimnnsirnninimrnninmniini STD Code Tel. No: Mobile No: E-mail Address: Address: Mobile No: Designation: Designation: