West Bengal Industrial Infrastructure Development Corporation

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1 Industral Infrastructure Development Corporaton Block DJ, Plot No. 10, Sector II, Saltlake Cty, Kolkata APPLICATION FORM FOR ALLOTMENT / ASSIGNMENT OF PLOT OF LAND / SHED / SDF BLDG. IN INDUSTRIAL GROWTH CENTRE / PARK [Please Submt the applcaton n trplcate n terms of the nstructons] I/We hereby apply for allotment/assgnment/transfer of land/shed/sdf Buldng for settng up ndustral unts/housng purpose/assgnment/shed measurng acres/ Sq. ft. modules/unts n WBIIDC's Industral Growth centre / Park. I/We hereby submt the followng nformaton so far as t relates to my/our ndustry as under. 1 Name of the applcant/frm/company 2 Address of regstered offce wth Telephone No., Fax No., E-mal ID and webste address 3 State whether t s (ownershp type) : v v v Propretory Partnershp Prvate Lmted Publc Lmted Jont Venture Co-operatve Socety 4 Nature of Project/Industry [Attach Detal Project Report alongwth Plant layout arrangement drawngs both n soft and hard fle(n duplcate) for Techno-Economc evaluaton]. 5 Requrement of Land/Shed/SDF Flat (In acres/sqm./no. of Unts of SDF, Shed) [Break up to be gven as per plant layout arrangement] a. Total area covered by Buldng/Factory/Sheds etc. b. Any area necessary for open storage (to be shown n Plant Layout Drawng) c. Any area necessary for future expanson (to be shown n Plant Layout Drawng) Total Area (In acres)

2 Industral Infrastructure Development Corporaton Block DJ, Plot No. 10, Sector II, Saltlake Cty, Kolkata () Proposed Products of manufacture ndcatng annual Capacty Engneerng tem Chemcal Item Others Nature & Qnty. Of Effluent (Vol /day) 6() Product Detals and Bye-Products, f any 7 whether proposed Project comes under small /medum /large scale ndustry 8 CAPITAL OUTLAY (Rs. In Lakhs) To commence producton To acheve Proposed Capacty of Producton Land & Buldng Plant & machnares Other Fxed Assets v Workng captal v Contngences Total 9 MEANS OF FINANCING (Rs. In lakhs) 10 Promoter's Equty Insttuton's Equty Term loan v Subsdy v Others Total Whether any fnancal Insttuton / Bank approved your project for fnancng. If yes, please enclose the photocopy of the letter. 11 Antcpated tme (to be reckoned from the date of delvery of possesson of land) a b c For constructon and nstallaton of plant & machnares For commencng producton To reach the proposed producton capacty Months Months Months

3 Industral Infrastructure Development Corporaton Block DJ, Plot No. 10, Sector II, Saltlake Cty, Kolkata EMPLOYMENT POTENTIALITIES To commence producton To acheve the Rated / Lcensed Capacty of Producton Techncal v v Manageral Supervsory Non-supervsory Sklled Un-Sklled Non- Techncal Manageral Supervsory Non-supervsory a Sklled b Un-Sklled Total 13 REQUIREMENTS OF INFRASTRUCTURE FACILITIES OR AMENITIES at Constructon Stage At Commencement of Producton To acheve rated/lcenced Water (Ltre/day) Power (KW/KVA Any other facltes and/ or amentes 14() Does the proposed project nvolve polluton of water / ar n any way? 14() Please ndcate whether N.O.C. receved from / appled to West Bengal Polluton Control Board. (Attach relevant documents) 15 Please attach photocopes of the regstraton no. of the Frm / Company 16 Foregn collaboratons, Jont Sector, f any, please affx name & address of the Collaborator & other detals n bref.

4 Industral Infrastructure Development Corporaton Block DJ, Plot No. 10, Sector II, Saltlake Cty, Kolkata Any other relevant nformaton the applcant lkes to furnsh Date : Sgnature : Enclosures : Declaraton I, son / daughter of resdng at, the propretor / one of the partner / Drectors of the applcant frm / Company do hereby declare that the statements made and nformaton dsclosed n the applcaton and the enclosures sent herewth sgned by me are true to the best of my nformaton and belef. If, however, any statement or nformaton dsclosed n the applcaton and the enclosures sent herewth are found to be untrue, the allotment and / or lease granted n persuence to ths applcaton shall be deemed to have been procured fradulently and consequents of such procurement of allotment / lease wll be dealt wth by the Corporaton n accordance wth the law. Any change / modfcaton / varaton n any of the nformaton dsclosed / change of consttuton of the Company / frm wll be communcated to the Corporaton at the earlest along wth supportng documents. Sgnature n full Place : Date: Desgnaton & Seal of Offce

5 Industral Infrastructure Development Corporaton Block DJ, Plot No. 10, Sector II, Saltlake Cty, Kolkata PARTICULARS OF PROMOTER / DIRECTOR To be submtted wth applcaton for allotment of land n WBIIDC Industral Growth centre. Please use extra sheet for for each Promoter / Drector. 1 2 Name of the Unt : Bo data of Promoter / Drector Name Age Address v Phone No. Offce : Resdence : v Fax No v E-Mal ID : Self v Academc Qualfcaton v Professonal/Work Experence Year Employer Desgnaton Functonal Dutes Salares Drawn 3 Functonal Responsbltes n the Unt 4 Equty / Loan contrbuton n the unt : 5 If assocated as Propretor / Drector / Shareholder wth Concerns other than n the Applcant unt, please gve detals.

6 Industral Infrastructure Development Corporaton Block DJ, Plot No. 10, Sector II, Saltlake Cty, Kolkata Instructons The applcant s requred to submt the followng documents as applcable : 1a. In case of Publc / Prvate Lmted Company / Jont Venture Company Photocopes of Certfcate of Regstraton alongwth Memorundum of Assocaton & Artcle of Assocaton and Balance sheet A bref Statement showng name of the Drectors, ther respectve shareholdng, term of offce, PAN, DIN etc. 1b. In case of Partnershp frm : Name and address of each Partner Certfed Copy of Certfcate of regstraton of Frm Copy of Partnershp Deed 1C. In case of Co-operatve Socety Regstraton Certfcate and Bye Laws 1d. In case of Foregn Collaboraton / JVC Agreement duly approved by Govt. of Inda: Approval Certfcate Certfcate of Regstraton of the Company 2 Audted annual accounts and annual report for last three years perod 3 Detaled Project report (n duplcate) contanng organsatonal, techncal, Market, fnancal, economc & envronmental analyss and plant layout drawng justfyng requrements of desred quantty of land. Soft fles of the report n MS word (for text materals), MS Excel (for fnancal computatons) and AutoCAD (for plant layout drawng) are to be submtted for techno-economc feasblty evaluaton of submtted project report. Relevant specfc nformaton requred n course evaluaton are also to be suppled. 4 Updated Income Tax Clearance Certfcate [If any document s not readly avalable, please ndcate the posble date of avalablty of such documents.]

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