LOAN APPLICATION FORM PRADHAN MANTRI MUDRE YOJANA ( PMMY )

( To be submitted along with documents as per the check list )

A. For office Use:

EnterpriseName Application Sl. No. Name of the Branch Category

Kishor / Tarun
B.Business Information:
Name of the
Enterprise
Constitution √ Proprietary Partnership Pvt. Ltd. Ltd. Company Any Others (specify)

Current
Business
State PIN Code
Address
Business Premises √ Rented Owned
Telephone No. Mobile No. 91
E-mail:
Business Existing
Activity Proposed
Date of Commencement(DD/MM/YYYY)
Whether the Unit is Registered √ Yes No
If Registered (Please mention:Registration no.
And the Act under which registered )
Registered office Address
Social Category √ SC ST OBC Minority Community
If Minority
√ Buddhists Muslims Christians Sikhs Jains Zoroastrians
Community
C.Background Information of Proprietor/ Partners/ Directors:
S.No Name Date of Sex Residential Address Academic Experience in the
Birth with Mobile No. Qualification line of activity
(Years)
1.
2.

S.No Id proof Id proof Address Address PAN Card/DIN Relationship with the
no. proof proof no. No. officials/ Director of the
bank if any
1.
2.

MMO BLDG, M.G ROAD, FORT, MUMBAI - 400023 FAX: 022-22626247 TEL: 022-43603229
D. Names of Associate Concerns and Nature of Association:

Names of Address of Presently Nature of Extent of Interest as a

Associate Associate Banking with Association Prop./Partner/ Director or Just
Concern Concern Concern Investor in Associate Concern

E. Banking/Credit Facilities Existing: (In Rs.)

Type of Presently Limit Outstanding Security Asset

Facilities Banking with Availed As on …… lodged classification
status
Savings Account N. A. N. A.
Current Account N. A. N. A.
Cash Credit
Term Loan
LC/BG
If banking with this bank, customer ID to be given here:

It is certified that our unit has not availed any loan from any other Bank / Financial Institution in the
past and I/we am/are not indebted to any other Bank / Financial Institution other than those
mentioned in column no. E above.

F. Credit Facilities Proposed:(In Rs.)

Type of Amount Purpose for which Details of Primary Security Offered

Facilities Required (with approx. value to be mentioned)
Cash Credit
Term Loan
LC/BG
Total
G.In case of Working Capital: Basis of CashCredit Limit applied:(In Rs.)

Actual Sales Projected

FY- FY- Sales Workin Inventory Debtors Creditor Promoter’s Limits
g Cycle s Contributio
in n
Months

MMO BLDG, M.G ROAD, FORT, MUMBAI - 400023 FAX: 022-22626247 TEL: 022-43603229
H. In case of Term loan requirements, the details of machinery/equipment may be given as
under:

Type of Purpose Name of Total Cost of Contribution being Loan Required

machine for which Supplier Machine made by the (Rs.)
/ Equipment required promoters(Rs.)

Total

Repayment period with Moratorium period requested for

I. Past Performance / Future Estimates: (In Rs.)

Past Performance / Future Estimates (Actual performance for two previous years, estimates for
current year and projections for next year to be provided for working capital facilities. However
for term loan facilities projections to be provided till the proposed year of repayment of loan)
Past Year-II Past Year-I Present Year Next Year
(Actual) (Actual) (Estimate) (Projection)
Net Sales
Net Profit
Capital (Net
Worth in case
of Companies)

J. Status Regarding Statutory Obligations:

Whether Remarks
Complied with (Any details in
Statutory Obligations (select Yes/No) connection withthe
If not applicable relevant obligation to be
then select N. A. given )
1. Registration under Shops and Establishment Act
2. Registration under MSME (Provisional /Final)
3. Drug License
4. Latest Sales Tax Return Filed
5.Latest Income Tax Returns Filed
6.Any other Statutory dues remaining outstanding

MMO BLDG, M.G ROAD, FORT, MUMBAI - 400023 FAX: 022-22626247 TEL: 022-43603229
K. Declaration:

I/We hereby certify that all information furnished by me/us is true, correct and complete. I/We
have no borrowing arrangements for the unit except as indicated in the application form. There
is/are no overdue / statutory dueowed by me/us. I/We shall furnish all other information that
may be required by Bank in connection with my/our application. The information may also be
exchanged by you with any agency you may deem fit. You, your representatives or Reserve
Bank of India or Mudra Ltd., or any other agency as authorised by you, may at any time,
inspect/ verify my/our assets, books of accounts etc. in our factory/business premises as given
above. You may take appropriate safeguards/action for recovery of bank’s dues.

Space for Photo Space for Photo Space for Photo

(Signatures of Proprietor/partner/ director whose photo is affixed above)

Date:___________________

Place:___________________

MMO BLDG, M.G ROAD, FORT, MUMBAI - 400023 FAX: 022-22626247 TEL: 022-43603229
 आवेदन सं./Application No. ददन ंक/Date:

फोटो/Photo
(फोटो पर हस्‍ताक्षर करें )
(Signature across photo)

प्रधानमंत्री मुद्रा योजना (पीएमएमवाय) के अंतर्गत ऋण के लिए आवेदन पत्र

Application Form for Loan under Pradhan Mantri Mudra Yojana (PMMY)
(लििु के अंतर्गत रु.50000/- तक के ऋण के लिए)
(For Loan upto Rs.50000/- under Shishu)

बैंक व िाखा का नाम जहां से ऋण लिया जाना है

__________________________________________________________________________ Name of
Bank & Branch from where Loan is required _____________________________________________________________
मैं, ________________________ के दिए एतद्द्व र रु. ________________के नकद स ख/ ओवरड्र फ्ट/ स वदि ऋण के दिए आवेदन
करत हं.
I hereby apply for Cash Credit/ Over Draft/ Term Loan of Rs. ____________________ for _______________________________

आवेदक/क ं 1. Father’s/ 1. श्री/Sh.

क /के न म 2. Husband’s 2. श्री/Sh.
Name of Name
Applicant(s)
संघटन वैयक्तिक संयुक्‍त स्‍व दमत्‍व भ गीद री अन्‍य
Constitution ( ) Individual Joint Proprietor Partnership Other

आव सीय पत
दकर ए
Residential Address
पर/स्‍वत्‍वRented/Owned
व्‍य वस दयक पत
Business Address दकर ए पर/स्‍वत्‍व Rented/Owned
जन्‍मदतदि आयु दिंगः पुरूष/स्‍त्री
Date of Birth Age Sex : Male/Female
शैक्षदणक य ग्‍यत अदशदक्षत 10वीं तक 12वीं तक स्‍न तक व्‍य वस दयक अन्‍य
Education Qualification () Illiterate Upto 10th 12th Graduate Professional Others
केव ईसी दस्‍त वेज व टर पहच न पत्र आि र सं . ड्र इदवंग ि इसेंस अन्‍य क ई
KYC Document(s) सं. Aadhaar No. Driving License No. Any others
Voter ID No.
पहच न स क्ष्‍य (उल्‍िेख करें )
ID Proof (pl. specify)
पत स क्ष्‍य (उल्‍िेख करें )
Address Proof (pl. specify)
टे िीफ न सं./Telephone No. : म ब .सं./Mobile No. : ई-मेि/E-mail :
व्‍य वस दयक गदतदवदि क दवद्यम न अवदि
प्रक र (प्रस्‍त दवत) Existing Period
Line of Business प्रस्‍त दवत
Activity (Purpose) Proposed
व दषिक दबक्री (ि ख रु.) दवद्यम नः प्रस्‍त दवतः
Annual Sales (Rs. in lakh) Existing : Proposed:
अनुभव, यदद ह /Experience, if any
स म दजक श्रेणी ( दचक्तित करें ) स म न्‍य अज अजज अदपव अल्‍प संख्‍यक
Social Category (Pls. tick ) General SC ST OBC Minority Community
यदद अल्‍प संख्‍यक बौद्ध मुक्तिम ईस ई दसख जैन प रसी अन्‍य
If Minority () Buddhists Muslims Christians Sikhs Jains Zoroastrians Others
आवश्‍यक ऋण सीसी/ओड्ी - CC/OD- स वदि ऋण/Term Loan –
Loan Amount Required रु./Rs. __________________ रु./Rs. ________________________
दवद्यम न ख त /त , ं क दववरण, यदद ह ं प्रक र (कृपय दचक्तित  करें ) बैंक व श ख क न म
Detail of Existing Account(s), if any Type (Pls. tick ) Name of Bank &
(जम /ऋण)/(Deposit/Loan) Branch
ख त सं. यदद ऋण ख त है त िी गई ऋण र दश रु/Rs.
A/c. No. If Loan A/c. amount of Loan taken
:: 2 ::
घोषणा/Declaration:

MMO BLDG, M.G ROAD, FORT, MUMBAI - 400023 FAX: 022-22626247 TEL: 022-43603229
मैं/हम घ षण करत हं/ करते हैं दक मेरे/ हम रे द्व र दी गई समस्‍त सूचन एं सत्‍य, सही एवं संपूणि हैं. मेरी/हम री इक ई के दिए
आवेदन पत्र में दकए गए उल्‍िेख के अि व क ई ऋण व्‍यवस्‍ि नहीं है. मैंने/हमने दकसी अन्‍य बैंक में आवेदन नहीं दकय है. मेरे/हम रे
द्व र ि ररत क ई अदतदे य/स ंदवदिक दे य नहीं है/हैं. मैं/हम मेरे/हम रे आवेदन से संबंदित ज नक री बैंक द्व र म ंगे ज ने पर उपिब्‍ि
कर उं ग /कर एं गे . ये सूचन एं आवश्‍यक समझे ज ने पर आप दकसी भी संस्‍ि से दवदनमय/स झ कर सकेंगे . आप, आपके प्रदतदनदि,
भ रतीय ररज़वि बैंक अिव मुद्र दि. अिव आप द्व र प्र दिकृत क ई भी संस्‍ि दकसी भी समय ऊपर ददए पते पर मेरी फैक्‍टर ी/व्‍य वस दयक
पररसर में मेरी/हम री आक्तिय , ं िेख बदहय ं क दनरीक्षण/सत्‍य पन कर सकते हैं. आप बैंक की दे यत ओं की वसूिी/सुरक्ष के दिए
समुदचत क रि व ई कर सकते हैं. I/We hereby certify that all information furnished by me/us is true,
correct and complete. I/We have no borrowing arrangements for the unit except as indicated in the application form.
I/We have not applied to any Bank. There is/are no overdue/statutory due owed by me/us. I/We shall furnish all
other information that may be required by Bank in connection with my/our application. The information may also be
exchanged by you with any agency you may deem fit. You, your representative or Reserve Bank of India of MUDRA
Ltd., or any other agency as authorized by you, may at any time, inspect/verify my/our assets, books of accounts etc.
in our factory/business premises as given above. You may take appropriate safeguards/action for recovery of bank’s
dues.

ददन ंक/Date: _____________________ आवेदक/कों के हस्‍ताक्षर/अंर्ूठा

स्‍ि न/Place: _____________________ Thumb Impression/Signature of Applicants (s)

(क य ििय उपय ग के दिए/For Office use only)

प वती क्तिप सं. …………………….. ऋण आवेदन सं . _______________ ददन ंक _______________
प्र प्‍तकत ि __________________
Acknowledgement Slip No……………………..loan Application No. ____________ dated ________________
Received by __________________

स्‍थान एवं लदनांक प्रालधकृत हस्‍ताक्षरी (िाखा की मुहर एवं हस्‍ताक्षर)

Place and Date Authorized Signatory (Branch Seal and sign)

--------------------------------------------------यह ं से क टें /Cut here-------------------------------------------------------

-

श्री/सुश्री __________________________________________ से रु. ______________ के दिए ऋण आवेदन ददन ंक ______________

पीएमएमव ई के अंतगित आवेदन प वती क्तिप सं. ______________

Acknowledgement slip no. ______________ for loan application under PMMY (Applicants copy)
Received with thanks from Sh./Smt. ________________loan application dated ________of Rs. _______

स्‍थान एवं लदनांक : प्रालधकृत हस्‍ताक्षरी (िाखा की मुहर एवं

हस्‍ताक्षर)
Place and Date : Authorized Signatory (Branch Seal and sign)

MMO BLDG, M.G ROAD, FORT, MUMBAI - 400023 FAX: 022-22626247 TEL: 022-43603229