Urban Self Employment Programme Form

THE URBAN SELF EMPLOYMENT PROGRAMME (USEP)
APPLICATION FORM

Name of Town ____________________________
	Sl. No. of application_____________
Urban Aoglomoration_______________________
Name of the applicant :
Father’s/Mothers/Husbands :
Permanent address:
Residing at the centre since : Whether employed presently : Yes/No
Whether holding Ration Card issued by the appropriate authority at the relevant town Urban Aoglomoration. : (a) In his /her own name: Yes/No If no, a certificate from the head of the family as per prescribed proforma should be enclosed.	.
Present Income of the family indicating the source (family means adult members include in the respective Ration Card).
Whether any loan has been taken bu the applicant from the Bank Financial institutions. Yes/No. (a) If ‘Yes’ Name of the Bank loc and amount of Loan taken. (b) Whether the applicant has made any default in payment of Loan.
Proposed Line of business and location thereof in the town (for details of activities under the scheme contact link Branches).
Amount of Loan applied for :
Purpose of Loans (a) Fixed Assets : (Please furnish particulars) (b) Working capital : (c) Anticipated sales per month: (d) Anticipated Income per month:	Rs._______________________ Rs._______________________ Rs._______________________ Rs._______________________
Experience in the line of business applied for (Some evidence to be forwarded).
Trading skills if any :
I/We certify that all information by me/us is true that no legal action has been/is being taken against me/us; that I/We shall furnish all other information that may be required by you with any agency you may deem fit; and that you, your representatives; representatives of Reserve Bank of India of any other agency is authorised by you, may at any time inspect, verify our assets, books of accounts, etc in due factory and business premises.



	Signature of Applicant/Borrower.

DECLARATION
SELF EMPLOYMENT PROGRAMME FOR URBAN POOR

I Shri/Smt___________________________________________________________________Son/Wife/Daughterof

______________________________________________________________________________an applicant for a

Loan of Rs.___________________ (Rupees _________________________________________________________

______________) under Self Employment Programme for the Urban Poor of the above Loan, I hereby declare as under

(i) I am a permanent resident of ________________________________________________________________
(Name of city/Town) and have lived continuously from________________________________________________
(date in this city/town).

(ii) The Total Income of my family as included in the Ration Card No._____________________________________
issued by ______________________________________________________________________________
______________________________________________________________________________________
(Name of the Authority issuing Ration Card)

(iii) I am not a borrower to any Bank/Credit Institution in respect of any loan for the purpose in undertaking activity similar to those under self-employment programme for the Urban Poor/under any scheme.

(iv) I further declare that I am not a defaulter to a Bank or any credit Institution.

Signed this day of ______________________
Signature:____________________________
Name of the Borrower:__________________
Address:_____________________________

Forwarded & Recommendation

(Headman) (M.L.A)

..............................................................

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