Application ID: (For office use)

APPLICATION FORM FOR FINANCIAL ASSISTANCE UNDER PRIME MINISTERS

EMPLOYMENT GENERATION PROGRAMME (PMEGP)
12 Name of the project / business activity proposed :

13 Amount of loan required (in Rs.)

Capital Expenditure Loan
Working
Building Type Workshed Machinery/ Pre
Capital /
Building Equipment/ Operative
Cash Credit Total
etc. Furniture Cost
Limit
Rented 0 151000 155000 255000 561000
Details of earlier or current Loan/Grant and subsidy availed from
14 Central/State Govt. Scheme/ or any other Similar Scheme.
Activity of the Project with Address Amount Year of Sanction

I certify that all information furnished by me is true; and that I and any of my dependent have not
borrowed any money under subsidy linked scheme from any Central / State Government or bank for
establishing any such project

Place:
Date: Signature of the Applicant

For Official Use only: (Rejected / to be placed before District Task force Committee)
Reason (if Rejected):

Place: Signature, Name & Designation of Officer

Date:
 NOTE

• Own contribution must be invested 5% for SC/ST/OBC/PHC/woman/ Ex-serviceman/ North

East Reason/Hill Boarder Area and 10% for General
• Total Project Cost should not exceed 25 lakhs for Manufacturing unit and 10 lakhs for
service unit.
• Applicant will not be entitled for additional Margin Money(Subsidy) in case of Own
Contribution over and above the prescribed limit.
• VIIIth pass for Manufacturing Unit above Rs.10 lakhs project cost and under Service Sector
above Rs.5 lakhs
• Application should be submitted complete in all respect along with attested copies of the
following documents:
1. Certificate of qualification-academic and technical (if project cost above 5 lakhs under
service industry or above 10 lakhs under Manufacturing industry)
2. Relevant Certificate for SC/ST/OBC/Minority/Ex-Servicemen/PHC
3. if Entrepreneur Development programme(EDP) training undergone (at least for two weeks)
then submit photocopy of the certificate
 DATA INPUT SHEET

Preference for sponsoring agency of the project to Bank: (mark √ )

KVIC √ KVIB DIC RURAL URBAN
1.1 Name of the Applicant/Institution
T MADHU
1.2

2 Gender Male √ Female

3 Address of the Proposed location of Unit: Rural √ Urban
T MADHU S/O T MADDILETI
H.NO 14-100-3-7
Taluk/Block: VELDURTHI
District: KURNOOL Pin: 518216
State: ANDHA PRADESH
Email: [email protected] Mobile: 9160372901

4 Qualification
Academic Technical
12th Pass mechanical engineering

5 Whether the applicant belongs to (mark √)

Ex- Hill
SC ST OBC PHC Service Minority Boarder General
man Area
√

Manu-
Whether the
√
Service
6 facturing
Unit
project (mark √) Unit
8 Name of the project / business activity proposed :

Legal Status:

Land ###

BUILDING DETAILS
Particulars Area Rate/Sq.ft Amount in Rs.
0.00
0.00
0.00
0.00
0.00
0.00
0.00

MACHINERY DETAILS
Particulars Qty. Rate Amount in Rs.
computer system 1 36000.00 36000.00
printer 1 15000.00 15000.00
0.00 Male
0.00
0.00
0.00 KVIC
0.00
0.00 DIC
0.00
0.00
0.00 Rura
0.00

Total 51000.00 No

d. Preliminary & Pre-operative Cost : 150000.00 SC

e. Furniture & Fixtures : 100000.00

f. Contingency/Others/Miscellaneous 5000.00

Working Capital : 255000.00

 Manu

Means of Financing ###

Own Contribution : 5%
Bank Finance : 95%
Margin Money (Govt. Subsidy) : 35%

DETAILS OF SALES Own

Rate/ Qantity Amount in Rs.
Particulars of Products
Unit
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Total 0.00

RAW MATERIALS
Particulars Unit Rate/Unit Reqd. Unit Amount In Rs.
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Total 0.00

WAGES
No. of Wages Per Month Amount in Rs.
Particulars
Worker Total Month 12
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Total 0 0.00

SALARY DETAILS
No. of Wages Per Month Amount in Rs.
Particulars
Staff Total Month 12
shop keeper 2 6000.00 144000.00
0.00
0.00
0.00
0.00
Total 2 144000.00

WORKING CAPITAL ESTIMATE

Element of Working Capital No. of Days

Stock in process 30

Finished goods 15

Receivable by 5

POWER ESTIMATE
Power Requirement

Repair and Maintanance 5.00% Rs. 5000.00

Power and Fuel Rs. 5000.00

Other Overhead Expenses Rs. 10000.00

Telephone Expenses Rs. 100.00

Stationery & Postage 5.00% Rs. 1000.00

Advertisement & Publicity 0.00% Rs. 0.00

Building Rent Rs. 12000.00

Other Miscelleneous Expenditure Rs. 5000.00

Rate of Interest 12.00%

Depreciation
On Building 90.00%
On Machinery 10.00%

INTRODUCTION

ABOUT THE PROMOTER

 PROJECT AT A GLANCE - TOP SHEET
1 Name of the Entreprenuer T MADHU

2 Constitution (legal Status) Individual

3 Father's/Spouce's Name 0

4 Unit Address : T MADHU S/O T MADDILETI

H.NO 14-100-3-7
Taluk/Block: VELDURTHI
District : VELDURTHI
Pin: 518216 State: ANDHA PRADESH
E-Mail : [email protected]
Mobile 9160372901
5 Product and By Product

6 Cost of Project : Rs. 3,28,940

Name of the project / business 0
activity proposed :
7 Means of Finance
Term Loan Rs. 3,12,493.00
KVIC Margin Money Rs. 1,15,129.00
Own Capital Rs. 16447.00

8 Debt Service :
Coverage Ratio

9 Pay Back Period : 5 Years

10 Project : 0 Months
Implementation
Period

11 Break Even Point :

12 Employment : 2

13 Power Requirement : 0

14 Major Raw materials : ,,

15 Estimated Annual : Rs. 0.00

Sales Turnover

PMEGP Project Report Page 10

 DETAILED PROJECT REPORT
1 INTRODUCTION :

2 ABOUT THE PROMOTER :

3 COST OF PROJECT
A. Fixed Capital Investment
a. Land : 0 Own

b. Workshed Area Sq.ft Rate in Rs. Amt. In Rs.

0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
Total 0.00
#REF!
C. Machinery Qty. Rate Amount in Rs.
computer system 1 36000.00 36000.00
printer 1 15000.00 15000.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
Total 51000.00

PMEGP Project Report Page 11

 d. Preliminary & Pre-operative Cost : Rs. 150000.00

e. Furniture & Fixtures : Rs. 100000.00

f. Contingency/Others/Miscellaneous Rs. 5000.00

Total Capital Expenditure : Rs. 306000.00

Working Capital : Rs. 22940.00

Total Cost Project : Rs. 328940.00

3.1 Means of Financing :

Own Contribution 5% Rs. 16447.00

Bank Finance : 95%

Term Loan Rs. 290700.00
Working Capital Rs. 21793.00

Total Rs. 312493.00

Margin Money (Govt. Subsidy) From KVIC 35% Rs. 115129.00

Margin Money Subsidy received From KVIC will be kept in term deposit as per norms of
PMEGP in the name of Beneficiary for three years in the financing branch.

3.2 STATEMENT SHOWING THE REPAYMENT OF TERM LOAN & WORKING CAPITAL :
TERM LOAN

Interest @
Year Opening Balance Installment Closing Balance
12.00%
1st 290700 0 290700 34884
2nd 290700 58140 232560 34884
3rd 232560 58140 174420 27907
4th 174420 58140 116280 20930
5th 116280 58140 58140 13954
6th 58140 58140 0 6977
7th 0 0 0 0
8th 0 0 0 0

WORKING CAPITAL

Interest @
Year Opening Balance Installment Closing Balance
12.00%
1st 21793 0 21793 2615
2nd 21793 4359 17434 2615
3rd 17434 4359 13076 2092
4th 13076 4359 8717 1569
5th 8717 4359 4359 1046
6th 4359 4359 0 523
7th 0 0 0 0
8th 0 0 0 0

PMEGP Project Report Page 12

3.3 STATEMENT SHOWING THE DEPRECIATION ON FIXED ASSETS:
WORKSHED @ 90.00%
Particulars 1st Year 2nd Year 3rd Year 4th Year 5th Year
Opening Balance 0 0 0 0 0
Depreciation 0 0 0 0 0
Closing Balance 0 0 0 0 0
MACHINERY @ 10.00%
Opening Balance 51000 45900 41310 37179 33461
Depreciation 5100 4590 4131 3718 3346
Closing Balance 45900 41310 37179 33461 30115
TOTAL DEPRECIATION
Workshed 0 0 0 0 0
Machinery 5100 4590 4131 3718 3346
Total 5100 4590 4131 3718 3346

4 Schedule of Sales Realization :

4.1 Details of Sales
Rate/ No. of Amount in Rs.
Particulars of Product Pair/Unit Pair/Unit
0
0 0.00 0 0.00
0 0.00 0 0.00
0 0.00 0 0.00
0 0.00 0 0.00
0 0.00 0 0.00
0 0.00 0 0.00
0 0.00 0 0.00
Total 0.00

4.2 Capacity Utilization of Sales

Particulars 1st Year 2nd Year 3rd Year 4th Year 5th Year

Capacity Utilization 70% 80% 90% 90% 90%

Sales / Receipts 0 0 0 0 0

5 Rawmaterials :
Particulars Unit Rate/unit Reqd.Unit Amount in Rs.
0 0 0.00 0 0.00
0 0 0.00 0 0.00
0 0 0.00 0 0.00
0 0 0.00 0 0.00
0 0 0.00 0 0.00
0 0 0.00 0 0.00
0 0 0.00 0 0.00
0 0 0.00 0 0.00
0 0 0.00 0 0.00
Total 0.00
5.1 Wages :
No. of Wages Amount in Rs.
Particulars Worker Per Month (Per Annum)
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
Total 0 0.00

PMEGP Project Report Page 13

5.2 Repairs and Maintenance : Rs. 5000.00

PMEGP Project Report Page 14

5.3 Power and Fuel : Rs. 5000.00

5.4 Other Overhead Expenses : Rs. 10000.00

6 Administrative Expenses :
6.1 Salary
shop keeper 2 6000.00 144000.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0.00 0.00
0 0.00 0.00
Total 2 144000.00

6.2 Telephone Expenses 100.00

6.4 Stationery & Postage 1000.00

6.5 Advertisement & Publicity 0.00

6.6 Workshed Rent 144000.00

6.7 Other Miscellaneous Expenses 5000.00

Total 294100.00
7 Capacity Utilization of Manufacturing & Administrative Expenses :
Particulars 1st Year 2nd Year 3rd Year 4th Year 5th Year
Capacity Utilization 70% 80% 90% 90% 90%
Manufacturing Expenses
Rawmaterials 0 0 0 0 0
Wages 0 0 0 0 0
Repairs & Maintenance 3500 4000 4500 4500 4500
Power & Fuel 3500 4000 4500 4500 4500
Other Overhead Expenses 7000 8000 9000 9000 9000
Administrative Expenses
Salary 144000 144000 144000 144000 144000
Postage Telephone Expenses 70 80 90 90 90
Stationery & Postage 700 800 900 900 900
Advertisement & Publicity 0 0 0 0 0
Workshed Rent 144000 144000 144000 144000 144000
Other Miscellaneous Expenses 3500 4000 4500 4500 4500
Total: 306270 308880 311490 311490 311490
8 Assessment of Working Capital :
Particulars Amount in Rs.
Sale 0.00

Manufacturing Expenses
Raw Material 0.00
Wages 0.00
Repair & Maintenance 5000.00
Power & Fuel 5000.00
Other Overhead Expenses 10000.00

Production Cost 20000.00

Administrative Cost 294100.00
Manufacturing Cost 314100.00

PMEGP Project Report Page 15

 Working Capital Estimate :
Element of Working Capital No of Days Basis Amount in Rs.
0 0 Material Cost 0.00

Stock in process 30 Production Cost 2000.00

Finished goods 15 Manufacturing Cost 15705.00

Receivable by 5 Manufacturing Cost 5235.00

Total Working Capital Requirement Per Cycle 22940.00

9 Financial Analysis
9.1 Projected Profit & Loss Account :
Particulars 0 Year 1st Year 2nd Year 3rd Year 4th Year
Sales / Receipts 0 0 0 0
0 0 0 0
Manufacturing Expenses
Rawmaterials 0 0 0 0
Wages 0 0 0 0
Repairs & Maintenance 3500 4000 4500 4500
Power & Fuel 3500 4000 4500 4500
Other Overhead Expenses 7000 8000 9000 9000
Depreciation 5100 4590 4131 3718
Production Cost 19100 20590 22131 21718
Administrative Expenses
Salary 144000 151200 158760 166698
Postage Telephone Expenses 70 80 90 90
Stationery & Postage 700 800 900 900
Advertisement & Publicity 0 0 0 0
Workshed Rent 144000 144000 144000 144000
Other Miscellaneous Expenses 3500 4000 4500 4500
Administrative Cost 292270 300080 308250 316188
Interest on Bank credit @ 12%
Term Loan 34884 34884 27907 20930
Working Capital Loan 2615 2615 2092 1569
Cost of Sale 348869 358169 360380 360405
Net Profit Before Tax -348869 -358169 -360380 -360405
Less Tax 0.00 0.00 0.00 0.00
Net Profit -348869 -358169 -360380 -360405

9.2 CALCULATION OF DEBT SERVICE CREDIT RATIO (D.S.C.R) :

Particulars 0 Year 1st Year 2nd Year 3rd Year 4th Year
Net Profit -348869 -358169 -360380 -360405
Add :
Depreciation 5100 4590 4131 3718
TOTAL - A -343769 -353579 -356249 -356687
Payments :
On Term Loan :
Interest 34884 34884 27907 20930
Installment 0 58140 58140 58140
On Working Capital
Interest 2615 2615 2092 1569
TOTAL - B 37499 95639 88139 80639
D.S.C.R = A/B
-9.17 -3.70 -4.04 -4.42
Average D.S.C.R

PMEGP Project Report Page 16

9.3 PROJECTED BALANCE SHEET :
Particulars 0 Year 1st Year 2nd Year 3rd Year 4th Year
LIABILITIES :
Promoters Capital 16447 16447 16447 16447
Profit -348869 -358169 -360380 -360405
Term Loan 290700 290700 232560 174420
Working Capital Loan 21793 21793 17434 13076
Current Liabilities 0 0 0 0
Sundry Creditors 0 0 0 0
-19929 -29229 -93939 -156463
ASSETS :
Gross Fixed Assets : 151000 145900 141310 137179
Less : Depreciation 5100 4590 4131 3718
Net Fixed Assets 145900 141310 137179 133461
Preliminary & Pre-Op. Expenses 150000 112500 84375 63281
Current Assets 21793 21793 17434 13076
Cash in Bank/Hand -187622 -192332 -248552 -302999
Total -19929 -29229 -93939 -156463

9.4 CASH FLOW STATEMENT :

Particulars 0 Year 1st Year 2nd Year 3rd Year 4th Year
Net Profit -348869 -358169 -360380 -360405
Add : Depreciation 5100 4590 4131 3718
Term Loan 290700 290700 232560 174420
Working Capital Loan 21793 21793 17434 13076
Promoters Capital 16447 0 0 0
Total -14829 -41086 -106255 -169192

Total Fixed Capital Invested 306000

Repayment of Term Loan 0 58140 58140 58140

Repayment of WC Loan 0 4359 4359 4359
Current Assets 21793 21793 17434 13076
Total 21793 84292 79933 75574

Opening Balance 0 -36622 -162000 -348188

Surplus -36622 -125378 -186188 -244766
Closing Balance -36622 -162000 -348188 -592954

9.5 BREAK EVEN POINT AND RATIO ANALYSIS :

Particulars 0 Year 1st Year 2nd Year 3rd Year 4th Year
Fixed Cost 332254 339554 340288 340836
Variable Cost 21715 23205 24223 23287
Total Cost 353969 362759 364511 364123

Sales 0 0 0 0

Contribution (Sales-VC) -21715 -23205 -24223 -23287

B.E.P in % -1530.06% -1463.27% -1404.81% -1463.63%

Break Even Sales in Rs. 0 0 0 0

Break Even Units #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Current Ratio 0.58 0.22 0.19 0.15

PMEGP Project Report Page 17

 Net Profit Ratio #DIV/0! #DIV/0! #DIV/0! #DIV/0!

PMEGP Project Report Page 18

 This Project Report has been prepared based on the data furnished by the entrepreneur whose details are
given in the application.
Place :
Date:
Prepared by :
Full Name : T MADHU

Signature of the Beneficiary

PMEGP Project Report Page 19

 PROJECT REPORT FOR

Affix latest
attested
Photograph

1 Name of the Entreprenuer T MADHU

1
2 Constitution (legal Status) Individual

3 Father's/Spouce's Name #REF!

5 Unit Address : T MADHU S/O T MADDILETI

H.NO 14-100-3-7
Taluk/Block: VELDURTHI

District : VELDURTHI
Pin: 518216 State: #REF!
Phone #REF!
E-Mail #REF!

6 Background of the Proprietor/Partners/Directors : Furnished detailed information in the DPR

7 Name of Business House/Group if any :

8 Details Other Companies/Units in the group :

Other Companies / Units in the Group (Rs. in Lakhs)
Name & Address Business Equity Reserves Loans Turnover *P.B.T **P.A.T
of Company / Unit

* Profit Before Tax ** Profit After Tax

`

8.1 How the activity was financed so far : ( To be filled up in case of existining unit Only )
*Source of Funds Security Rate of Repayment per Present O/s Amount of Default
Interest Month ( Rs. in '000 ) (if any)

8.2 If the Unit is an ancillary one, undertaking to

which it is catering and its address :
8.3 Employment : Present Proposed
0 0
0 0
0 0
0 0
0 0
0 0
0 0
shop keeper 2
0 0
0 0
0 0
0 0
Total 2

9 Project Details for Proposed New Unit : Copy of detailed project report is enclosed.
a Expansion / Mordenisation :

b Setting up of New unit :

c Activity for proposed new unit :

d Product / Item proposed to undertake :

9.1 Capacity (Furnish the details of Installed capacity & production : (No. in Units/ Qty. in Kg./Volume in liter per annum)
Capacity is arrived at on the basis of Days working on shift basis
Product & Present Installed Maximum Prod. Proposed Installed Maximum Prod.
By-product if any Capacity Achieved Capacity of 1st Year envisaged
70.00% 19100

9.3 State the manufacturing process in brief :

9.4 Has the proposed process ever been tried in the
country or newly adopted? :

9.5 Technical Arrangements :

9.6 Describe arrangement for Key Official

for managing the proposed unit :
Technical Manpower

Administrative Manpower

Accounting personnel

9.7 Particulars of Land Existing Proposed

Location of the Land :
Area of Land
Status of the Land
Nature of Land
Availability of Water :

9.8 Particulars of Building Existing Proposed

(Enclose the plan & Estimation for the proposed Building) Area Value in Rs. Status Area Value Status
Factory Building :

Ancillary Building

Storage

Total 0.00 0.00

9.9 Plant and Machinery Existing (Value in Rs.) Proposed (Value in Rs.)
Indigenous 51000.00

Imported

(Enclose the plan layout of the existing plant and machinery )

9.10 Rawmaterials / Components
Req. of Raw material/Components/Chemicals Qty. in Nos./Kgs./Ton Rate/Nos./Kgs/Tons Value in Rs.

Total 0.00

9.11 Utilities (Furnish details on requirement, availability, adequacy, qualitative aspects etc..)
Particulars of Utilities Contracted Load Connected Load Further requirement
in HP/KW/W in HP/KW/W in HP/KW/W
Power

Water

Fuel

Others (Specify)
9.12 Environment Aspect of the Project :

9.13 Requirement of Manpower for the Project :

Particulars of Manpower Total Requirement Salary/Wages per month Cost per Annum
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
shop keeper 2 6000.00 144000.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
0 0 0.00 0.00
Total 2 144000.00

9.14 Schedule of Implementation : BAR CHART

Activities Date of Commencement Expected Date of Completion
a. Acquisition of Land
b. Development of Land
c. Civil Works for Factory / Building
Machinery / Foundation etc..
d. Plant & Machinery
Imported
Indigenous
e. Arrangement for power
f. Arrangement for water
g. Errection of equipment
h. Commissioning
I. Procurement of Raw materials/Chemicals
j. Trail Runs
k. Commercial Production
10 Cost of Project :
(Rs. in '000)
Sr.No. Particulars Already Incurred To be Incurred Total Cost
A Land including Development 0.00 0.00

B Building & Other Civil Works 0.00 0.00

C Plant and Machinery

1. Indigenous 51000.00 51000.00
2. Imported 0.00

D Furniture & Fixture 100000.00 100000.00

E Testing equipment 0.00

F Miscellaneous Fixed Assets 0.00

G Errection & Installation Charges 0.00

H Contingency 5000.00 5000.00

I Preliminary & Pre-Op. Cost 150000.00 150000.00

J Provision for
1. Buildings 0.00
2. Plant & Machinery 0.00
3. Other Fixed Assets 0.00

K Working Capital for one 22940.00 22940.00

Operating Cycle

L Total 0.00 328940.00 328940.00

 11 Means of Financing :
(Rs. in '000)
Sr.No. Particulars Amount already Amount Proposed Total
Raised to be Raised
A Equity / Promoters Contribution 16447.00 16447.00

B Reserves 0.00

C Term Loans 312493.00 312493.00

D Unsecured Loans and Deposits 0.00

(Indicate sources, roi, repayment etc)

E Deferred Payment 0.00

Arrangements including Suppliers credit

F Subsidy
Central Government 115129.00 115129.00
State Government 0.00

G Seed Capital 0.00

H Internal Cash Accruals 0.00

I Other Sources (Specify) 0.00

J Total 0.00 328940.00 328940.00

11.1 In case internal accruals are taken as

source of finance explain the basis of
estimation of internal accruals :

11.2 Indicate source from which expenditure

already incurred has been financed :

11.3 % of Promoters contribution of the :

total cost of project
 12 Marketing & Selling Arrangements of the Product :

13 Projected Profitability : Projected Profitability Statement given in the

Detailed Project Report.

14 Projected Cash flow Statement : Projected Cash flow Statement given in the
Detailed Project Report.

% of Cash Sales in Total Sales :

Period in which payment is received Days

in respect of Credit Sales

Average Credit Available on Purchase : Days

15 Working Capital Required for the : Rs. 22940.00

anticipated turnover

16 Repayment Programme : Detailed Repayment programme for Term loan and

Working capital loan have been given in the DPR.

17 Details of Securities to be Offered :

17.1 Primary ( Furnish details for term loan and : :

working capital loan separately )
17.2 Collateral, if any (Details) :

17.3 Details of Guarantor(s) :

1. Name
2. Residential Address :

3. Occupation :
4. Details of movable & immovable
properties owned by him /her/other
family members

5 Details of any other similar guarantees:

if any, given to other institutions

18 Government Consents :
(Give deatails of various licenses / consents required to be obtained from various authorities for the proposed project)

19 DECLARATION

I / We hereby declare that the information given herein before and the statements and other
papers enclosed are, to the best of our knowledge and belief, true and correct in all particulars

Date : 0 Signature of the Borrower

Place : 0 Name & Designation (In case of Regd. Inst.)
 Project Report on

Prepared By:
#REF!
Khadi & V.I. Commission
#REF!
#REF!
#REF! State: #REF!
e-Mail:
Ph. No.: Fax: