Government of India Ministry of Micro, Small and Medium Enterprises Rajiv Gandhi Udyami Mitra Yojana (RGUMY) Application

for Udyami (Entrepreneur) Registration (Please read the guidelines and instructions before filling up the form) 1. Name of Udyami
Title(Tick one) First Name Middle Name Last Name

Mr

Mrs

Ms

Gender

Male

Female

2. Fathers Name
First Name Middle Name Last Name

3. Present Contact Address

City/Town: District : State : PIN 4. Permanent Contact Address

City/Town: District : State : PIN 5. Phone Number / Mobile STD Code Mobile 0 6. Email Address

Phone

7. Date of Birth Date(dd/mm/yyyy) City/Town State 8. Proof of Age Class 10 Certificate Driving Licence Passport Other

If other, write detail Page 1 of 3

9. Detail of Education

Literate 12th

Primary Graduate

8th Post Graduate

10th

If other, write detail 10. Proof of Identity

(Optional) Passport PAN Card Driving Licence Voter /Card

If other, write detail

11. Category

General

Scheduled Caste Physically Handicapped

Scheduled Tribe

Woman

Domicile of North-Eastern Region

12. Details of Eligibility Type of Course: Vocational Training (VT) from ITI SDP In case VT from ITI , Trade Name Name of the Course, if not ITI Course Duration:Two Weeks 1- 6 Months One Year ESDP EDP Diploma or Higher

Details of Institution where EDP/ SDP/ ESDP/ VT completed : Name City/Town: District : State : PIN Date of Enrolment Date of Passing 13. Experience Details Duration : Nil Less than One year Own Business Service Trading More than one year

Nature of Experience: Job Type of activity: Manufacturing 14. Investment Capability (margin money) Rs. Nil Rs. 10,000- 50,000

Rs 50,001- 1,00,000 Rs. 10,00,001 and above

Rs. 1,00,001-3,00,000

Rs. 3,00,001 10,00,000

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15. Land and Building Not Available 16. Details of Proposed Industry Available on rent Manufacturing Enterprise Own Land Available Service Enterprise

Investment in Plant & Machinery/Equipment Rs. 17. Registration Fee If payable : Exempted Cash Payable Rs. 1000/Cheque Pay Order/Demand Draft

Cheque / Pay Order / Demand Draft Detail : Date Cheque/Pay Order /Demand Draft No Name of Bank Branch I declare that the above information is correct to the best of my knowledge and belief. Amount Rs.

Date : Enclosures : 1. 2. 3. 4. 5.

(Signature of Applicant)

Instructions to fill up the form : Boxes should be filled with CAPITAL letters only. Write only one letter / number in a box. Tick Mark boxes with symbol wherever necessary. Date should be filled in dd / mm / yyyy format. Registration Fee is exempted for beneficiaries from special category i.e. SC/ ST/ physically handicapped/ women / beneficiaries from North-Eastern Region. 6. Form should be filled up neatly. 7. EDP Entrepreneurship Development Programme 8. SDP Skill Development Programme 9. ESDP - Entrepreneurship cum Skill Development Programme ________________________________________________________________________________ 1. 2. 3. 4. 5.

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