MSME
Application Information Form
AWARD 2015, HARYANA
Classication for the companies will be as per the Government of India’s denition which is based on the investment in the plant and machinery for manufacturing and in the equipment for enterprises providing or rendering the services.
·¤ ÂçÙØæð´ ·¤æ ß»èü·¤ÚU æ ÖæÚUÌ âÚU·¤æÚU ·¤è ÂçÚUÖæáæ ·ð¤ ¥ÙéâæÚU ç·¤Øæ ÁæØð»æ, Áæð ç·¤ ©U ÂæÎÙ æð æ ×ð´ Üæ ÅU °ß¢ ×àæèÙÚUè ×ð´ ·é¤Ü çÙßðàæ ÌÍæ âðßæ æð æ ×ð´ ©U·¤ÚU ææð´ ×ð´ ç·¤Øð »Øð ·é¤Ü çÙßðàæ ÂÚU ¥æ ææçÚUÌ ãñÐ 1. Is your company registered with Ministry of Micro, Small & Medium Enterprises, Government of India? ( Øæ ¥æ·¤è ·¤ ÂÙè âé ×, Ü æê °ß¢ × Ø× ©Ulæð» ×¢ ææÜØ, ÖæÚUÌ âÚU·¤æÚU mUæÚUæ ÚUçÁSÅUÇüU ãñU?)
YES(ãUæ¢)
NO(ÙãUè´)
If yes, which category do you fail under? (ØçÎ ãUæ¡, Ìæð ¥æ 緤âæ æð æè ×ð´ ¥æÌð ãñ´¢?) Micro (âé ×)
Small (Ü æé )
Medium (× Ø× )
SSI Registration/EM Part-2 No. (°â.°â.¥æ§ü. ÚUçÁSÅðUþàæÙ / §ü.°×. ÂæÅüU-2 Ù ÕÚU) _____________________________________________ Date(çÎÙ梷¤) _______________ Note: The SSI Registration/EM number is compulsory for the registered MSMEs (ÚUçÁSÅUÇüU °×.°â.°×.§ü. ·ð¤ çÜ° °â.°â.¥æ§ü. ÚUçÁSÅðUþàæÙ/§ü.°×. Ù ÕÚU ÂýÎæÙ ·¤ÚUÙæ ¥çÙßæØü ãñU) 2. Company Information (·¤ ÂÙè ·¤æ çßßÚU æ ) Name of the Company (·¤ ÂÙè ·¤æ Ùæ×)
Year of Establishment (SÍæÂÙæ ßáü)
Registered Address (¢Áè·ë¤Ì ÂÌæ)
Telephone (ȤæðÙ Ù ÕÚU)
FAX (Èñ¤ â)
Website (ßðÕâæ§ÅU)
Email (§ü-×ðÜ)
Ownership Pattern (Sßæç× ß ·¤æ Âý·¤æÚU) Proprietary (Sßæ×è)
Partnership (âæÛæðÎæÚUè)
Are you a 100% EOU? ( Øæ ¥æ 100 ÂýçÌàæÌ §ü.¥æð.Øê. ãUñ?) Total Number of employee (including contract labour) (·¤×ü¿æçÚUØæð´ Male (ÂéM¤á)
Private Limited (Âýæ§ßðÅU çÜç×ÅðUÇU)
Public Limited (Âç Ü·¤ çÜç×ÅðUÇU)
Yes
No
·¤è ·é¤Ü ⢠Øæ (·¤æò ÅUþð ÅU ÜðÕÚU âçãUÌ))
Female (×çãUÜæ)
Proprietors / Partners / Promoters (àæèáü ÂýÕ¢ æÙ) 1. _____________________________________________________ Designation (ÂÎ): __________________________________ Age (¥æØé): ________ 2. _____________________________________________________ Designation (ÂÎ): __________________________________ Age (¥æØé): ________ 3. Operational Details Please select ONE INDUSTRY from the following 13 sectors, you would like to be nominated under for the awards: Food & Agro Products (¹æl÷Ø Auto Components (¥æòÅUæð
°ß¢ ·ë¤çá ©U ÂæÎ)
·¤ ÂæðÙð´Å÷Uâ)
Metal and Metal Products (ÜæðãUæ Paper & Packaging (ÂðÂÚU
Apparel, Fashion Garment & Accessories (ÂçÚU
°ß¢ ÜæðãUæ ©U ÂæÎ)
°ß¢ Âñ·ð¤çÁ¢»)
Textile (including readymade garments) (ÅñU
IT & ITES (except Hardware) (¥æ§üÅUè-¥æ§üÅUè§ü°â
(ãUæÇüUßðØÚU ·ð¤ ¥çÌçÚUQ¤))
ææÙ, Èñ¤àæÙ ÂçÚU ææÙ °ß¢ âãUæØ·¤ °âðâÚUèÊæ)
Scientic, Measuring & Laboratory Instruments (ßñ Handicrafts and Wooden Furniture (ãñU
ææçÙ·¤, ×æÂÙð °ß¢ ÂýØæð»àææÜæ ·ð¤ ©U·¤ÚU æ)
ÇUè·ý¤æ Å÷U⠰ߢ Ü·¤ÇUè ȤÙèü¿ÚU)
âÅUæ§Ëâ (ÚÔUçÇU×ðÇU ßS ææð´ âçãUÌ))
Engineering Goods (including machinery Electrical & Electronic Goods & Components (§¢ÁèçÙØçÚ¢U» âæ×æÙ (×àæèÙÚUè, §Üðç
ÅþU·¤Ü, §Üð ÅþUæðçÙ â ©U ÂæÎ ß ©U·¤ÚU ææð´ âçãUÌ)) Page 1 / 4
MSME
AWARD 2015, HARYANA
Major Products Total no. of Plants (Manufacturing Sector) OR delivery centers (IT-ITeS) OR Hotel / Resorts
·é¤Ü âØ¢ æ (çßçÙ×æü æ æð æ) Øæ çÇUÜèßÚUè âð´ÅUâü (¥æ§üÅUè-¥æ§üÅUè§ü°â) Øæ ãUæðÅUÜ/çÚUâæðÅ÷Uüâ
Location of Plants (Manufacturing/delivery centres (IT-ITeS) / no. of Rooms (Hotel/Resorts)
Total Installed capacity of all plants and units of measurement P.A./no. of seats (IT-ITeS) /no. of rooms (Hotels/Resorts)
âØ¢ æ (çßçÙ×æü æ æð æ) Øæ çÇUÜèßÚUè âð´ÅUâü (¥æ§üÅUè-¥æ§üÅUè§ü°â) Øæ ãUæðÅUÜ/çÚUâæðÅ÷Uüâ ·¤æ ÂÌæ
âÖè âØ¢ ææð´ ·¤è ·é¤Ü SÍæçÂÌ æ×Ìæ °ß¢ ×æ ·¤è §ü·¤æ§üØæ¢, Âè.°. âèÅUæð´ ·¤è ⢠Øæ(¥æ§üÅUè-¥æ§üÅUè§ü°â) Øæ ·¤×ÚUæð´ ·¤è ⢠Øæ (ãUæðÅUÜ/çÚUâæðÅ÷Uüâ)
Investment in plant & machinery/equipment (excluding land & building) a) Manufacturing Upto T25 lakh (T25 Üæ¹ Ì·¤)
More than T25 lakh & Upto T5 crore (T25 Üæ¹ âð ¥ç æ·¤ °ß¢ T5 ·¤ÚUæðÇU¸ Ì·¤)
More than T5 crore & upto T10 crore (T5 ·¤ÚUæðÇU¸ âð ¥ç æ·¤ °ß¢ T10 ·¤ÚUæðÇU¸ Ì·¤)
b) Service Sector Upto T10 lakh (T10 Üæ¹ Ì·¤)
More than T10 lakh & Upto T2 crore (T10 Üæ¹ âð ¥ç æ·¤ °ß¢ T2 ·¤ÚUæðÇU¸ Ì·¤)
More than T2 crore & upto T5 crore (T2 ·¤ÚUæðÇU¸ âð ¥ç æ·¤ °ß¢ T5 ·¤ÚUæðÇU¸ Ì·¤)
4. Financial Details (Information will be strictly used for analytical purpose and kept strictly condential) FY09-10 (çßç æØ ßáü 09-10)
Financial Details (Tcrore) çßç æØ çßßÚU æ - ·¤ÚUæðÇU¸ ×ð´
FY10-11 (çßç æØ ßáü 10-11)
Total Income (·é¤Ü ¥æØ) Net Prot (·é¤Ü ÜæÖ) Export Revenue (çÙØæüÌ ÚUæÁSß/¥æØ) Note: Kindly only provide the audited gures for FY09-10 and FY10-11 (ÙæðÅUÑ çßç æØ ßáü 09-10 °ß¢ 10-11 ·ð¤ ·ð¤ßÜ ¥¢·ð¤ç æÌ ¥æ¢·¤Çð¸U ©UÂÜ æ ·¤ÚUæ°¢)
Please specify the top ve-exporting countries with (·ë¤ÂØæ çÙØæüÌ ·¤ÚUÙð ßæÜð Â梿 àæèáü Îðàææð´ ·¤æð ©UËÜðç¹Ì ·¤ÚÔU)
5. Miscellaneous (¥ Ø/çßçß æ) Do you have a credit rating report? If yes, kindly mention the agency ( Øæ ¥æ·¤ð¤ Âæâ ·ðý¤çÇUÅU ÚÔUçÅ¢U» çÚUÂæÅüU ãñU?) ØçÎ ãUæ¡ Ìæð ·ë¤ÂØæ °Áð´âè ·¤æ ©UËÜð¹ ·¤ÚÔ´U
Haryana MSMEs are competitive in Global Market? (ãUçÚUØæ ææ ·ð¤ °×.°â.°×.§ü. ßñçàß·¤ SÌÚU ÂÚU ÂýçÌSÂhUè ãñU?)
YES (ãUæ¡)
NO (ÙãUè´)
Benets derived by the company from the State : (Kindly rate them in the order of 1 to 8 with 1 being the highest and 8 being lowest) (ÂýÎðàæ âð ·¤ ÂÙè ·¤æð ç×Üð ÜæÖ (·ë¤ÂØæ § ãð´U °·¤ âð ¥æÆU Ì·¤ ·ý¤× ×ð´ ßÚUèØÌæ Îð´, çÁâ×ð´ °·¤ ¥ç æ·¤Ì× °ß¢ ¥æÆU ØÙÌ× ßçÚUØÌæ / S·¤æðÚU ãñU)) Benets (ÜæÖ)
Rank (Úñ´U·¤)
Benets (ÜæÖ)
Government support for entrepreneurship (©Ulç×Øæð´ ·ð¤ çÜ° âÚU·¤æÚUè âãUæØÌæ)
Obtaining Finance (çß Ì Âýæ Ì ·¤ÚUÙæ)
Raw material procurement (·¤ ¿ð ×æÜ ·¤è ¹ÚUèÎ)
Skilled Manpower (·é¤àæÜ ×ñÙÂæòßÚU)
Better infrastructure (ÕðãUÌÚU ÕéçÙØæÎè âéçß ææ°¢)
Export Promotion Measures (çÙØæüÌ â¢ß æüÙ ·ð¤ ©UÂæØ)
Technology up-gradation (Ì·¤Ùè·¤è ©U ÙØÙ)
Others, please specify (ØçÎ ¥ Ø, Ìæð ·ë¤ÂØæ ©UËÜð¹ ·¤ÚÔ´U)
Rank (Úñ´U·¤)
Page 2 / 4
6. Declaration (
ææðá ææ)
This is to certify that the above information is true and correct to the best of my knowledge
MSME
(×ñ´ ØãU â ØæçÂÌ ·¤ÚUÌæ ãê¢U ç·¤ ©UÂÚUæðQ¤ âê¿Ùæ°¢ ×ðÚUè ÁæÙ·¤æÚUè ·ð¤ ¥ÙéâæÚU âãUè °ß¢ â Ø ãñ´U) Name of the Respondent (Âý Øé
AWARD 2015, HARYANA
æÚUÎæÌæ ·¤æ Ùæ×)
Designation (ÂÎ)
Mobile No. (×æðÕæ§Ü
Date (çÎÙ梷¤)
Signature (ãUSÌæ
Ù ÕÚU)
æÚU)
Company Stamp (·¤ ÂÙè
·¤è ×æðãUÚU)
Enclose a small write up on the Company’s Achievement in the two years, Client’s Testimonials, Marketing Brochure, Bio-Data of the Proprietor / Partner / Promoter, Certicate including SSI / EM registration number & any other relevant information using additional sheets
(·ë¤ÂØæ çÂÀUÜð Îæð ßáæðZ ×ð´ ·¤ ÂÙè ·¤è ©UÂÜç æØæð´, »ýæãU·¤ Âýàæ¢âæ- æ, ×æ·ðü¤çÅ¢U», ÕýæðàæÚU, ÂýæðÂÚUæ§üÅUÚU/ÂæÅüUÙÚU/Âý×æðÅUÚU ·¤æ ÕæØæðÇUæÅUæ, °â.°â.¥æ§ü./§ü.°×. ÚUçÁSÅðUþàæÙ Ù ÕÚU ·¤æ âçÅüUçȤ·ð¤ÅU °ß¢ ¥ Ø â¢Õ¢ç æÌ ÁæÙ·¤æÚUè °·¤ ÀUæðÅðU Üð¹/çßßÚU æ ·ð¤ âæÍ ¥çÌçÚUQ¤ ÂëcÆUæð´/ÂðÁ ·¤æ ÂýØæð» ·¤ÚUÌð ãéU° â¢Ü Ù ·¤ÚÔ´U ) 7. Nomination Fees (Ùæ×梷¤Ù
àæéË·¤)
Please send a Demand Draft fpr nomination fee. You can also Register & make the payment online at www.dainikbhaskar.com/MSME_awards_of_Haryana
(·ë¤ÂØæ Ùæ×梷¤Ù Ȥèâ ·¤æ çÇU×æ ÇU ÇþUæ ÅU ÕÙæ°¢ ¥Íßæ ãU×æÚUè ßðÕâæ§üÅU www.dainikbhaskar.com/MSME_awards_of_Haryana ÂÚU Áæ·¤ÚU ÚUçÁSÅUÚU ·¤ÚÔ´U ß ¥æòÙÜæ§üÙ Âð×ð´ÅU ·¤ÚÔ´U) Micro Enterprises (âé
× ©Ulæð»)
Small Enterprises (Ü
T500/DD NUMBER
æé ©Ulæð»)
Medium Enterprises (×
T1000/DATE
Ø× ©Ulæð»)
T2000/DRAW ON
AMOUNT
The Demand Draft should be payable to DAINIK BHASKAR at Chandigarh and sent along with the complete application form to the address mentioned below OR submitted at your nearest Dainik Bhaskar ofce. Please mentioned “DAINIK BHASKAR MSME Award-2015, Haryana” on Envelope.
(çÇU×æ ÇU ÇþUæ ÅU ÎñçÙ·¤ ÖæS·¤ÚU, ¿¢ÇUè»É¸U ·ð¤ Ùæ× âð ÎðØ ãUæð»æÐ Âê æüÌØæ ÖÚUæ ãéU¥æ Ȥæ×ü çÇU×æ ÇU ÇþUæ ÅU ·ð¤ âæÍ Ùè¿ð çΰ »Øð ÂÌð ÂÚU ÖðÁð´/ÂðýçáÌ ·¤ÚÔ´U, ¥Íßæ ¥ÂÙð ÙÁÎè·¤è ÎñçÙ·¤ ÖæS·¤ÚU ·¤æØæüÜØ ×ð´ Á×æ ·¤ÚU氢Р·ë¤ÂØæ çÜȤæÈð¤ ÂÚU ÎñçÙ·¤ ÖæS·¤ÚU °×.°â.°×.§ü. ÂéÚUS·¤æÚU 2015, ãUçÚUØæ ææ çܹÙæ Ùæ ÖêÜð´)
Please send the completed questionnaires to:
MSME
AWARD 2015, HARYANA
Plot No. 11-12, Sector 25-D, Chandigarh-160014 Phone: 0172-3988884 FAX: 0172-2704212, 2709967
ÜæòÅU Ù ÕÚU 11-12, âð ÅUÚU 25-ÇUè, ¿¢ÇUè»É¸U- 160 014 ȤæðÙÑ 0172-3988884 Èñ¤ âÑ 0172-2704212, 2709967
The application form is designed to elicit information for Dainik Bhaskar MSME Awards-2015, Haryana. Your organisation’s nancial information will never be shared with any other person OR organisation. (§â Ȥæ×ü ·¤æð çßàæðá ÌæñÚU ÂÚU ÎñçÙ·¤ ÖæS·¤ÚU °×.°â.°×.§ü. ÂéÚUS·¤æÚU 2015, ãUçÚUØæ ææ ·¤è ÁæÙ·¤æÚUè ·¤æð Âý·¤æàæ
×ð´ ÜæÙð ·ð¤ çÜ° çÇUÁæ§Ù ç·¤Øæ »Øæ ãñUÐ ¥æ·ð¤ â¢SÍæÙ ·¤è çß æèØ ÁæÙ·¤æÚUè ç·¤âè Öè ¥ Ø ÃØçQ¤ Øæ â¢SÍæÙ Ì·¤ ÙãUè´ ÂãéU¿ð»èд) Page 3 / 4
MSME
8. Awards (ÂéÚUS·¤æÚU)
AWARD 2015, HARYANA
SECTOR
MICRO
SMALL
MEDIUM
TOTAL
Food & Agro Products
1
1
1
3
Auto Components
1
1
1
3
Apparel, Fashion Garment & Accessories
1
1
1
3
Engineering Goods (including Machinery, Electrical and Electronic Goods and Components
1
1
1
3
Scientic, Measuring & Laboratory Instruments
1
1
1
3
IT & ITeS (except Hardware)
1
1
1
3
Metal and Metal Products
1
1
1
3
Paper & Packaging
1
1
1
3
Handicrafts & Wooden Furniture
1
1
1
3
Textile (Including Readymade garments)
1
1
1
3
Jury’s Special Award for Special Initiatives
1
1
Chief Minister’s Special Award
1
1
Chairman’s Award
1
1
Business Bhaskar Award
1
1
SPECIAL AWARDS
Haryana Emerging MSME Entrepreneur Award
1
1
Best Global MSME Award
1
1
Best Woman Entrepreneur Award
1
1
Best Young Entrepreneur Award
1
1
TOTAL AWARDS
38
For more information please contact your nearest Dainik Bhaskar ofce at the number mentioned below or email us at : msmeawards@dainikbhaskargroup.com (¥ç æ·¤ ÁæÙ·¤æÚUè ·ð¤ çÜ° Ùè¿ð çΰ »Øð Ù ÕÚUæð´ ÂÚU ¥ÂÙð ÙÁÎè·¤è ÎñçÙ·¤ ÖæS·¤ÚU ·¤æØæüÜØ âð â ·ü¤ ·¤ÚÔ´U, Øæ §ü-×ðÜ ·¤ÚÔU msmeawards@dainikbhaskargroup.com)
Register online at:
w w w. d a i n i k b h a s k a r. c o m / M S M E _ a w a r d s _ o f _ H a r y a n a Dainik Bhaskar, Plot No. 11-12, Sector 25-D, Chandigarh-160014 Partners
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dainikbhaskar.com dainik Disclaimer: Companies and personal information provided by the participatory respondents as mentioned in the application form should be authentic. Disclosers of falsied information will result in exclusion from the award activity. Mandatory eld in the application invitation from should be populated for nomination purpose. Nominations without the mandatory participation fees will not be considered. Awards in each sector and category will be subjected to a minimum number of nominations received. Award methodology and quantitative model is Dun & Bradsteel India's exclusive popularity and will not be shared or disclosed. Award winners are subjected to the discretion of DB Corp. Ltd. and Dun & Breadsteel Information Services India Pvt. Ltd. This questionnaires is the property of Dun & Bradsteel India.
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