To be submitted by Indian Enterprises seeking financial assistance under TIFAC-SIDBI Re ol ing fund for Tec!

nology Inno ation (SRI"A#$ %Application Format $ &ART A ' Brief about t!e (nit 1.1 Particulars of the Enterprise 1. Name 2. Constitution 3. Type of enterprise (Proprietorship, Partnership firm, Company, Micro / Small / Medium / Large Enterprises etc. 4. !ear of incorporation / commencement of operations 5. "ddress of registered office and site of operations 6. Main Promoter(s names # contact details (tel. / email 1.2 Particulars of promoters Name # "ge Educational / professional $ualification No of !ears of professional e%perience No of !ears of entrepreneurial e%perience & Sta'e in

1.3 Present line of (usiness and technology / product successfully de)eloped (y the entity in the last * years+ 1.4 Technology 'no,-ho, partner of the proposed pro.ect, if any (name designation ,ith educational and professional (ac'ground affiliation address, telephone, fa%, e - mail etc. &ART B' Tec!nical Information 2. Pro.ect title+ 2.1 /ac'ground+ 2.2 Pro.ect o(.ecti)es + 2.3 Ma.or Targets to (e achie)ed during the pro.ect period+ 2.4 Process / Products proposed to (e scaled up / commerciali0ed under the pro.ect along ,ith specifications etc. + 2.5 1etailed technology description in product / process+

2.6 2hat is the specialty / no)elty / uni$ueness / inno)ation a(out the proposed technology + 2.7 2or' already carried out for proof of concept / )alidation of technology # at ,hat scale + 2.8 2hether the technology has (een already patented. 3f yes, pro)ide the details + 2.9 Process flo, - charts / schematic diagram etc. + 2.10 4a, materials and their a)aila(ility + 2.11 Comparati)e ad)antages/disad)antages of proposed technology o)er the con)entional / emerging technologies and (rief comments on competitions / challenges 2.12 Techno-economics, cost (enefit analysis and demand statistics in ne%t 5/6 years (please pro)ide list of potential customers along ,ith proof of documents 2.13 En)ironmental Clearance 4e$uired, if any + 2.14 Total Pro.ect 1uration (in months + 2.15 2or' Plan indicating important acti)ities / milestones # duration, time scheduling ((ar-chart + 2.16 1eli)era(les of the pro.ect # proposed capacity for scale up+ 2.17 List of e%isting facilities already a)aila(le for the proposed pro.ect (land, (uilding, machinery, soft,are, manpo,er, utilities etc.

&ART C' Financial Re)uirement 3.1 Total &ro*ect Cost' Pro.ect head Cost of construction / augmentation of factory shed for the pro.ect Technology 9no,-ho, fee / patent / licensing E$uipment / machinery / :tilities Consuma(les / 4a, Materials E$uipment for Testing # E)aluation / 7uality Control Manpo,er Salaries Mar'eting related e%penses 2or'ing Capital Margin ;thers (pl specify Contingency Total 3.2 +eans of Finance ' +eans of finance "dditional Share capital :nsecured loans from << "ssistance sought under S43="N "ssistance from other 83s, if any ;thers (pl specify Total Amount %Rs, lak!$ "rea / 7ty ./ specifications / Capacity Company / 8irm Contri(ution (4s. la'h Contri(ution from 8und (4s. la'h Total Cost (4s. la'h

3.3 1etailed /rea'-up of cost for the follo,ing /udget >eads (in ta(ular form + 3.3.1 Capital E$uipment / plants # machinery ,ith detailed specifications 3.3.2 Testing # La(oratory E$uipment 3.3.3 Manpo,er Salaries 3.3.4 Consuma(les / 4a, Materials 3.3.5 :tilities 3.4 What is the ad)antage of the proposed technology in terms of (usiness opportunities? 3.5 2hether this proposal has (een su(mitted to any other agency for funding support (if yes, gi)e details

3.6 Financial performance' 3n case of e%isting entity, (rief (usiness highlights gi)en (elo, (Pl, enclose last FY audited accounts with auditors report) (Rs, lak!$ &articular Fy-, Fy-, &articular Fy-, Fy-, 4e)enue Share Capital (promoters E/13T" Share capital (others @ Profit "fter Ta% (P"T Net ,orth / "ccumulated losses 3nital / product de) e%penses not /an' term loans ,ritten off Net profit Margin (& :nsec loans - promoters 1e(t E$uity 4atio (1E4 :nsec loans - others /an' (orro,ings - 2C * Please provide details 3.7 Credit / /an'ing facilities from S31/3 / other (an's / 8ls / PE or AC or "ngel 3n)estors in respect of customer (4s. la'h PE / AC / "ngel in) / /an', (ranch 8acility Sanc amt ;utstanding

3.7.1 2hether any o)erdues in any (an'ing credit facilities (y the applicant enterprise / associate concerns in past 5 !ears. 3.7.2 ,hether any of the accounts of the enterprise / associate concern classified as NP" / any restructuring done during past 6 !ears or any ;TS done e)er. 3.7.3 2hether any default in promotersB personal / consumer loans / credit card payments, etc. 3.8 Tentati)e (usiness pro.ections (4s. la'h Particular
>C

8irst !ear
>5 >C

Second !ear
>5 >C

Third !ear
>5 >C

8ourth !ear
>5

Sales
P"T

4. 9ey strengths and ris' factors 5. "ny other rele)ant information

DEC.ARATI/#

3 / 2e certify that all information furnished (y me / us a(o)e and in the appendi% / anne%ure / statements and other papers enclosed is trueD 3 / ,e ha)e no (orro,ing arrangements for the unit ,ith any (an' / 83 e%cept as indicated in the applicationD that there are no o)er dues/statutory dues/go)ernment en$uiry / proceedings / prosecution against the unit / associate concerns / promoters/directors e%cept as indicated in the preliminary informationD that no legal action has (een/is (eing ta'en against the unit / associate concerns / promoters/directors+ that 3 / ,e shall furnish all other information that may (e re$uired (y S31/3 in connection ,ith my / our application and 3 / 2e ha)e no o(.ection to your furnishing the information su(mitted (y me / us to any agency as you may deem fit in connection ,ith consideration of the assistance. 2e ha)e no o(.ection to S31/3 / its representati)es ma'ing suita(le en$uires ,hile considering the application. Signature' #ame0 Designation 1it! Seal &lace ' Date '