06-Apr-2021 01:12 PM

GOVERNMENT OF KARNATAKA

DIRECTORATE OF INDUSTRIES & COMMERCE

2nd FLOOR, KHANIJA BHAVAN (SOUTH WING)
NO. 49, RACE COURSE ROAD,
BANGALORE - 560 001. INDIA
TEL: 91-80-22386796
FAX: 91-80-22389909

APPLICATION FORM
FOR APPROVAL OF PROJECTS BY
STATE HIGH LEVEL CLEARANCE COMMITTEE/
STATE LEVEL SINGLE WINDOW CLEARANCE
COMMITTEE

KARNATAKA UDYOG MITRA

(A Government of Karnataka Organisation)
3rd Floor, Khanija Bhavan(East Wing),
No. 49, Race Course Road, BANGALORE - 560 001. India.
TEL: 91-80-22282392/22285659/22286632 Fax: 91-80-22266063
Email: md@kumbangalore.com

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Company Details

Name of the Company /Unit/Trust

Constitution of the Establishment

Category of the Entrepreneur

Type of Proposal

Correspondence Address

Pin Code

Phone Number

Mobile

Email ID

Corporate Address

Pin Code

Phone Number

Mobile

Email ID

Name of the Managing Director / CEO / Chief Promoter / Trustee

/ Managing Partner / Proprietor

Name of the authorized coordinating person

Is your proposed project Solar/ Wind Project

Do you have existing business

Products proposed to Manufacture / Activity

Item Activity

Item Description

Item code

Proposed Annual capacity

Unit Capacity

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Do your manufacturing process have By-product/co-product :

Production Details ( For five Years)

Year Year 1 Year 2 Year 3 Year 4 Year 5

Quantity(meter,
kg,liters,numbers)

Sales Value( in Crores)

Environment Clearance From

Category of industry ( As per KSPCB guidelines )

Type of Activity for Proposed Industry

Pollution Category

Distance of the project site from Sensitive Location ( world

heritage center/national monument/Protected Forest/
Sanctuaries Etc)

Distance of the project site from Water bodies

Distance of the project site from Nearest Habitation

Distance of the project site from Road(NH/SH/District Road ETC

Whether company Plans for zero discharge

Government Special Project

Cost of the Project

Cost of the project Rs. ( In Crores)

Land

Building

Plant & Machinery

Working Capital Margin

Contingency

Others

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Total

Means of Finance

Means of Finance Rs. ( In Crores)

Promoters Equity

Institutions Equity

Foreign Equity

Term Loans

Subsidy/Grants

Others

Total

Whether Foreign Technology Agreement is Envisaged ?

Term Loan

External Commercial Borrowing (ECB)/Foreign Direct Investment

(FDI)

Production to be exported

Employment Existing Proposed

Top/Middle-Management 0

Supervisory 0

UnSkilled/SemiSkilled 0

Skilled 0

Total 0

Expected Employees Skill set

Expected Date of Commencement of Trial Production

Expected Date of Commencement of Commercial Production

Ancillary Potential

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Land Requested for Approval and Land Utilization Details in Sq.Meters

Land required for the proposed project ( SqMts)

Building type Land required( in SqMts) Plinth Area ( In SqMts) Built- up Area( In SqMts)

1 acre = 4047 sqmts

FAR ( Built up area / Total Land Area )

Plot Coverage =( Plinth Area/ Land Required )

Mode of Acquisition of proposed Land

District Taluk Village/Industrial Land Owner Consent Survey no/Hissa Extent In

Area Obtained No Acres

Power Requirement

Power required for the proposed project in KVA

Do you have any plans of Captive Generation of power

Water Requirement

Source of Water Quantity( In KLPD)

Status of Clearance from Central/State Government

EOU Letter LOI FIPB IEM_GOI Mining Lease

Incentives and Assistance Details

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Incentive Sought from Govt. of Karnataka

Incentive & Concessions Sought Over & above Policy(applicable for the Mega projects)

Incentive Sought Incentive Concessions Policy

Assistance Sought from Govt. of Karnataka

Assistance Name Assistance Description

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Details of Promoters/Directors

Name

Designation

Address

Office Number

Mobile Number

E-mail

PAN

Net worth

National Identity No/ Aadhar

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Details of Authorized Person

Name of the Company /Unit/Trust

Name of the Authorized person

Designation

Address

Mobile Number

Email

PAN

National Identity No/ Aadhaar

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 For SC / ST ,
Backward Classes
For General ,Minority &
Sl. No Project Cost
Category(With tax) Solar/Wind
Projects
(With tax)
1 Projects above Rs.15 Cr and up to Rs.30 Cr Rs.23,600 Rs.11,800
2 Projects above Rs.30 Cr and up to Rs.50 Cr Rs.47,200 Rs.23,600
3 Projects above Rs.50 Cr and up to Rs.100 Cr Rs.1,18,000 Rs.59,000
4 Projects above Rs.100 Cr and up to Rs.250 Cr Rs.2,36,000 Rs.1,18,000
5 Projects above Rs.250 Cr and up to Rs.500 Cr Rs.3,54,000 Rs.1,77,000
6 Projects above Rs.500 Cr and up to Rs.1000 Cr Rs.5,31,000 Rs.2,65,000
7 Projects above Rs.1000 Cr and up to Rs.5000 Cr Rs.8,85,000 Rs.4,42,500
8 Projects above Rs.5000 Cr Rs.17,70,000 Rs.8,85,000
 Private Sector
Private Sector
Undertaking -
Partnership Undertaking - Joint Sector Public Sector
Proprietary Private Co-Operative One Person Section 8 Others(Please
Document List firm Public Limited Undertaking Undertaking LLP Trust
Limited Undertaking Company Company Specify)
Company
Company

Brief note on the present activities of

M M M M M M M M M M M M
the company
Project layout map M M M M M M M M M M M M
Project implementation schedule M M M M M M M M M M M M
Detailed Project Report M M M M M M M M M M M M
IT return of individual promoter M M M M M M M M M M M NA
CA Certified Net worth Statement of
M M M M M M M M M M M NA
Each Individual Promoter/Director
Pan card of Promoter/ Company M M M M M M M M M M M NA
M M M M M M M M M M M
Audited Account Report Of The
If BS>year If BS>year If BS>year If BS>year If BS>year If BS>year If BS>year If BS>year If BS>year If BS>year If BS>year NA
concern
else NM else NM else NM else NM else NM else NM else NM else NM else NM else NM else NM
Partnership deed/ Registration of
NA M NA NA NA NA NA NA NA NA NA NA
Firms
Incorporation certificate issued by
NA NA M M M NA M M M M NA NA
ROC
Memorandum and Article of
NA NA M M M NA M M M M NA NA
Association Company/Form 32
M M M M M M M M M M
CA Certified Net worth Statement of
NA If BS>year If BS>year If BS>year If BS>year If BS>year If BS>year If BS>year If BS>year If BS>year If BS>year NA
the Company
else NM else NM else NM else NM else NM else NM else NM else NM else NM else NM
Authorization Letter M M M M M M M M M M M NA
Registration Certificate of Co-
NA NA NA NA NA M NA NA NA NA M NA
Operative Society/Trust
Society By Law NA NA NA NA NA M NA NA NA NA M NA

*All The above mentioned Document must be PDF only Min size 50kb Max size 10mb
For all above selection Authorised Person Photo and multiple Promoters Photo and IT return
is Mandatory
File type - jpg, jpeg,png - min 50kb Max 10mb

Legend - M = Mandatory
NM = Non Mandatory
BS= Business Start Date
NA= Not applicable