FORM NO: 011101530 Date of Online Filing : 11 Mar 2013

LETTER - "EM PART-I"

Sir/Madam

You have successfully filed an on-line application for Entrepreneur Memorandum part-I for
registration of your Micro/Small/Medium scale unit. You may kindly print the on-line application (3 copies)
and send the signed copies of application along with required attachments as indicated below

a) Enclose a self-certified copy of Power of Attorney / Board Resolution / Society Resolution,

wherever applicable, while signing as Partner / Managing Director of Authorised Person.

b) Enclose a certified/notarized copy of the Partnership Deed / Memorandum of association / Articles of

Association in case of Medium Enterprises.

You may kindly note that your on-line filed application will be processed only after receipt of signed
copies of application (3 copies) along with required attachments in the concerned GM, DIC office.

You are requested to send the signed copies of on-line filed application within 30 days.

Thanking you.
General Manager,
District Industries Centre,
Besides Govt. ITI,
Balaga Srikakulam,
Srikakulam.
eMail: gm_dic_sklm@ap.gov.in
Phone No: 08942 - 225895
To,

Name : THAMMINENI VENKATA SRIRAM CHIRA,

Door No : 1-1
Street : PALAKONDA ROAD
Village / Town : AMADALAVALASA,
Mandal : AMADALAVALASA
District : SRIKAKULAM
State : ANDHRAPRADESH
Pincode : 532185
FORM NO: 011101530 Date of Online Filing : 11 Mar 2013

ENTREPRENEURS MEMORANDUM FOR SETTING UP MICRO,SMALL OR MEDIUM ENTERPRISE

PART-I

1. NAME OF APPLICANT

SURNAME THAMMINENI

MIDDLE NAME

LASTNAME VENKATA SRIRAM CHIRA

2.
(a) ADDRESS OF COMMUNICATION

1-1,PALAKONDA ROAD,AMADALAVALASA,AMADALAVALASA,SRIKAKULAM,ANDHRAPRADESH,
532185

(i) TELEPHONE NUMBER -

(ii) FAX NUMBER -

(iii) CELL PHONE NUMBER 9966901399

(iv) E-MAIL samrajyalakshmisurgicals

(v) WEB-SITE nil

(b) PERMANENT RESIDENTIAL ADDRESS (MAIN APPLICANT)

1-1,PALAKONDA ROAD,AMADALAVALASA,AMADALAVALASA,SRIKAKULAM,ANDHRAPRADESH, 532185

(i) TELEPHONE NUMBER -

(ii) FAX NUMBER -

(iii) CELL PHONE NUMBER 9966901399

(iv) E-MAIL samrajyalakshmisurgicals

3. NAME OF PROPOSED ENTERPRISE (if decided)

M/S SAMRAJYALAKSHMI SURGICALS

4. PROPOSED LOCATION OF ENTERPRISE

(i) VILLAGE / TOWN / MUNCIPALITY Ragolu SURVEY / PLOT NO

CODE 01254300 188/1, 193/4

(ii) TEHSIL / TALUK / MANDAL Srikakulam

CODE 0034

(iii) DISTRICT Srikakulam

CODE 011

(iv) STATE ANDHRAPRADESH

CODE 28

(v) PIN CODE

(vi) AREA (RURAL-1, URBAN-2) 1

5. CATEGORY OF ENTERPRISE
2
(MICRO-1, SMALL-2, MEDIUM-3)
FORM NO: 011101530 Date of Online Filing : 11 Mar 2013

6. NATURE OF ACTIVITY
(i) MANUFACTURE Y

(ii) SERVICE

7. NATURE OF OPERATION
1
(Perennial-1, Seasonal-2, Casual-3)

8. WHETHER THE UNIT WILL BE AN ANCILLARY

2
(Yes-1, No-2)

9. PROPOSED SCHEDULE OF INSTALLATION OF PLANT AND Dec/2013 (MM/YYYY)

MACHINERY(MM/YYYY)

10. TYPE OF ORGANIZATION

(PROPRIETARY-1, HINDU UNDIVIDED FAMILY-2, PARTNERSHIP-3, 3
CO-OPERATIVE-4, PRIVATE LIMITED COMPANY-5, PUBLIC LIMITED
COMPANY-6, SELF-HELP GROUP-7, OTHERS-8)

11. (a) MAIN MANUFACTURING / SERVICE ACTIVITY

NAME Manufacture of polymer/ synthetic / PVC water storage tanks and other
plastic products n.e.c.
CODE(NIC 2004*) 25209

(b) PRODUCTS TO BE MANUFACTURED / SERVICE TO BE PROVIDED

1 NAME Medical Disposables (Thermo Welded Plastic Product)

CODE(ASICC 2000*) 42606

(*) Codes for activities and products / services as per classification specified from time to time by the office of
the Development Commissioner (Small Scale Industries), to be filled in by District Industries Centre or the office
where the Entrepreneurs' Memorandum is to be submitted.

12.
(a) PROPOSED INVESTMENT IN FIXED ASSETS [Rupees in lakh]

(i) LAND (OWNED-01/RENTED-02/LEASED-03) 0 1

APPROXIMATE VALUE * 45.00

(ii) BUILDING (OWNED-01/RENTED-02/LEASED-03) 0 1

APPROXIMATE VALUE * 60.00

(iii) PLANT AND MACHINERY VALUE* 380.00

(In case of manufacturing enterprise)

(iv) EQUIPMENT VALUE* 0.00

(In case of service enterprise)

(v) FOREIGN EQUITY, IF ANY VALUE* 0.00

13. INSTALLED CAPACITY (proposed) PER ANNUM

FORM NO: 011101530 Date of Online Filing : 11 Mar 2013

(i) PLANT A

SNo PRODUCT NAME QUANTITY UNITS

1 Medical Disposables (Thermo Welded Plastic Product) 9,500,000.00 Nos

(ii) PLANT B

SNo PRODUCT NAME QUANTITY UNITS

14. POWER LOAD (ANTICIPATED) H.P / K.W. QTY UNIT

120.00 HP

15. (a) (i) OTHER SOURCE OF ENERGY / POWER

[IF REQUIRED]
(NO POWER NEEDED-1, COAL-2, OIL-3, LIQUID PETROLIUM GAS-4, ELECTRICITY FROM GRID-5,
ELECTRICITY FROM GENERATOR-6, NON-CONVENTIONAL ENERGY-7, TRADITIONAL
ENERGY/FIREWOOD-8)

(ii) If no power required, specify reasons;

(b) INDICATE ANNUAL REQUIREMENT

SNo. SOURCE OF ENERGY QTY UNIT

16. EXPECTED EMPLOYMENT (No.s)

(i) MANAGEMENT & OFFICE STAFF 10

(ii) SUPERVISORY 20

(iii) WORKERS 50

17. ENTREPRENEUR'S PROFILE (OF ALL PARTNERS / DIRECTORS OF THE ORGANISATION-USE

SEPARATE SHEETS, IF NEEDED)
FORM NO: 011101530 Date of Online Filing : 11 Mar 2013

(a) NAME THAMMINENI VENKATA SRIRAM CHIRA

(i) MALE (M) / FEMALE (F) M

(ii) SC(1) / ST(2) / OBC(3 ) / OTHERS(4) / PHYSICALLY CHALLENGED(5) 3

(iii) KNOWLEDGE LEVEL 4

[TECHNICAL GRADUATE-1, MANAGEMENT GRADUATE-2, POST GRADUATE-3,
OTHER GRADUATE-4, UNDER-GRADUATE-5, ANY OTHER LOWER-6]

(iv) EQUITY PARTICIPATION (in Lakhs) 145.50

(Percentage of total equity ) 30.00 %

(v) STAKE IN OTHER MANUFACTURING ENTERPRISES 2

(Yes-1, No-2 )

(a) NAME THAMMINENI VANISREE

(i) MALE (M) / FEMALE (F) F

(ii) SC(1) / ST(2) / OBC(3 ) / OTHERS(4) / PHYSICALLY CHALLENGED(5) 3

(iii) KNOWLEDGE LEVEL 5

[TECHNICAL GRADUATE-1, MANAGEMENT GRADUATE-2, POST GRADUATE-3,
OTHER GRADUATE-4, UNDER-GRADUATE-5, ANY OTHER LOWER-6]

(iv) EQUITY PARTICIPATION (in Lakhs) 242.50

(Percentage of total equity ) 50.00 %

(v) STAKE IN OTHER MANUFACTURING ENTERPRISES 2

(Yes-1, No-2 )

(a) NAME THAMMINENI SITARAM

(i) MALE (M) / FEMALE (F) M

(ii) SC(1) / ST(2) / OBC(3 ) / OTHERS(4) / PHYSICALLY CHALLENGED(5) 3

(iii) KNOWLEDGE LEVEL 4

[TECHNICAL GRADUATE-1, MANAGEMENT GRADUATE-2, POST GRADUATE-3,
OTHER GRADUATE-4, UNDER-GRADUATE-5, ANY OTHER LOWER-6]

(iv) EQUITY PARTICIPATION (in Lakhs) 97.00

(Percentage of total equity ) 20.00 %

(v) STAKE IN OTHER MANUFACTURING ENTERPRISES 2

(Yes-1, No-2 )
FORM NO: 011101530 Date of Online Filing : 11 Mar 2013

(DD/MM/YYYY)

18. EXPECTED SCHEDULE OF COMMENCEMENT OF PRODUCTION / ACTIVITY 23/04/2014

DATE :

PLACE :
[SIGNATURE OF THE APPLICANT/AUTHORISED PERSON]

NAME OF THE PROPRIETOR/PARTNER/MANAGING DIRECTOR

(a) Enclose a self-certified copy of power of Attorney/Board Resolution/Society Resolution, wherever applicable,
while signing as Partner/Managing Director or Authorised Person.
(b) Enclose a certified/notarized copy of the Partnership Deed/Memorandum of Association/Articles of Association in
case of Medium Enterprises.
____________________________________________________________________________________________

Undertaking

This is to certify that the information furnished in the memorandum in Form No. 011101530 is true and correct to the
best of my knowledge and belief.

DATE :

PLACE :
[SIGNATURE OF THE APPLICANT / AUTHORISED PERSON]