(For Offline Application)

APPLICATION FORM
Assistance of Capital Investment Subsidy to micro Enterprise, Assistance for Interest
Subsidy to MSMEs, Assistance for Reimbursement of CGTMSE Fees
(Aatmanirbhar Gujarat Scheme for assistance to MSMEs)

(Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022)

Step-1: Common Incentive Form

Common Details

1. Name of the Enterprise As Per Registration

2. Type of activity Manufacturing/service

3. Status Of Enterprise(As per GR Dated Micro / Small / Medium

05/10/2022)
4. Constitution of the Enterprise Proprietorship/ Partnership/
Company/ society/ Others
5. Udyam /IEM/LOP Registration no. No:……………..
Date:
Category as per Registration Certificate. Micro/Small/Medium /Large
6. Category Of Enterprise New or existing

If existing
Expansion/Diversification
7. Date of Production of Existing Enterprise
Date :
8. Proposed Date of Production of Date:
NEW/Expansion /Diversification
OR Date:
Actual Date of Commercial Production of
NEW/Expansion /Diversification

9. Office Address with pin code No:

8. Factory Address with pin code No:

9. Tele No.: Office :

Mobile:
10. Email Id :
Alternative Email Id :
Promotor Details
12. Promoter Type Individual/other entity
13. Name, Address & Contact details of the
Promoters
14. Date of Birth of all promoters

15. PAN No. of all promoters

16. Gender of all promoters Male/Female/Third Gender

17. Category of all promoters General/SC/ST

18. Differently abled Yes/no

19. E-mail ID of all promoters :

20. Educational Qualifications of all promoters :

21. If promoters of the Enterprise are below 35 Date of Birth of the promoter Date:
years. …………
( as on the date of term loan sanction) Term loan sanction date: ………....
22. If promoters of the Enterprise are Differently Attach the proof for Differently
Abled Abled from Competent Authority
(100% owned by Differently Abled)
23. If promoters of the Enterprise are Women YES/NO
Entrepreneurs
(100% owned by woman)
24. Total Equity(Share Holding pattern)

Authorized Person details

25. Name, Address

26. Contact details of the authorised person Mo.No.:…………………

27. PAN No.

28. E-mail ID

Enterprise detail As per GoG GR

29. Investment and Turn Over Details as per GoG GR (Give details separately for each
units)
Name of the unit/units
 Gross Investment in Plant and Machinery or
Equipment

Annual Turnover

PAN No

GST Registration No.

30. Enterprise located in Taluka Category I/II/III/Municipal corporation area

Taluka Name: __________________

31. Whether Micro / Small unit is situated in Own/ Rental / Leased premises
Note: Below scheme is applicable only to Manufacturing – Micro & Small enterprise.
32. For Reimbursement of CGTMSE Fees
1. Term Loan amount covered under RS. ……..
CGTMSE:
2. Guarantee fee & Annual charges paid to RS. ……..
CGTMSE:
3. CGPAN No:
4. Expiry date
Step-2 : Specific Form for Interest subsidy, Capital subsidy and CGTMSE fees
Reimursement :
33. Category New or existing or Existing applying
as new
If Existing
Expansion/Diversification
34. Service activity as per Annexure- A of GR Name of the activity
dated 05/10/2022
35. Project Financial Details
(RS. In Lakhs)
Means of Finance
Cost of Project Sr.No Particulars Amount
Sr.No Particulars Amount 1 Promoters
1 Land Contribution
2 Building 2 Term Loan
3 Plant & M/c 3 Unsecured
4 Other Loan
5 Other Construction 4 Internal
6 Project related Resource
infrastructure 5 Deposit
7 Preliminary and Pre- 6 Assistance
operative Expenses From
8 Working Capital Government
9 Technology,Design,Patent of India
10 Other Charges of P&M 7 Other
Total Total
36. For the Enterprise going under Expansion/Diversification
A. Cost of Project: - (Rs.In
Lakhs)
Sr. Particulars Gross Fixed capital Proposed/ actual
No investment before gross Fixed Capital
Expansion/Diversification Investment for
(Rs. In Lakhs) up to Dt. Expansion/
(Summation of all Diversification/
existing Enterprise ) Forward
Integration/Backward
Integration
1 Land
2 Building
3 Plant & M/c
4 Other
5 Other Construction
6 Project related
infrastructure
7 Preliminary and Pre-
operative Expenses
8 Working Capital
 9 Technology,Design,Patent
10 Other Charges of P&M
Total
Is the investment made in expansion 50% or more ?

37. Utilisation of existing installed capacity in 1) FY

Preceding Three financial year 2) FY
3) FY
Percentage Increases in Installed capacity of
Existing Product
38. Manufacturing Item Detail (Need To Submit Separate Detail for each Product )

Product sector

NIC Code

Name of the Product

Actual item Produce

HSN Code

Annual Production Capacity

Capacity of Product in terms of units

39. Land Area Detail (Separately for each unit)

Project Name

Address

Country

State

District

Taluka

Village

Pin Code

Taluka category

Land Area (sq. Mtr)

40. Start Up Details (if Applicable) Yes/No

Registration Number

Registration date

Registration authority
41. Name and Address of the bank/Financial
Institution separately.
E-mail ID of the Bank
Contact Number of Bank Branch
Amount of first loan sanctioned and date Rs………..Lakhs
Date:
Date of First Disbursement of Term Loan Date:
Interest Rate of Term Loan
Term Loan Account No.
IFSC code No.
Branch Name
Branch Code No.
42. GPCB approval for CTE/CCA (if applicable) CTE for new ……………..
CCA/ CTO for expansion No………………
Date:
Valid up to Date:
43. Employment Details for Existing Enterprise: -
Sr.No Particulars Total Local % of Local
Employment
1 Manager/Supervisor
2 Workers
Total

Employment Details for proposed project:-

Sr.No Particulars Total Local % of Local
Employment
1 Manager/Supervisor
2 Workers
Total
44. Employment Details for service activity
(No. of permanent employees)

45. Details of any other financial assistance YES/NO

granted by GOG/GOI If, yes please attach details in separate
sheet.
46. I/We hereby opt for date of eligibility for Interest subsidy from the
Date of production [ ] Dt. DD/MM/YYYY
OR
Date of first disbursement [ ] Dt. DD/MM/YYYY
47. Declaration:
I hereby declare that the information, statement & documents submitted are to the
best of my knowledge & belief, true and correct in all particulars. I am abide with the
terms, condition, eligibility criteria and parameters specified in the Government
Resolution , Guideline and as amended time to time, under the Aatmanirbhar Gujarat
Scheme for assistance to MSMEs. I also declare that I am authorized by the enterprise
to sign and submit the application and related details with relevant documents.
 Undertaking
I/We undertake and declare to comply with the terms, conditions, eligibility,
particulars and parameters of the Resolution No.MIS-102022-1271(1)-I(ch)Dated:
05/10/2022 , guideline and as amended, applicable resolutions under the Aatmanirbhar
Gujarat Scheme for assistance to MSMEs of the government of Gujarat and Guideline for GR
No. MIS-102022-1271(1)-I(ch) Dated: 05/10/2022.
I/We applying for Capital Subsidy and Interest Subsidy/CGTMSE fees Assistance under the
scheme will observe the following conditions and if I/We will Violate these conditions than
I/We shall be liable to pay back the assistance paid and the same will be recovered as
arrears of land revenue or in any other appropriate manner Govt. May deem fit along with
interest at the rate of 18% per annum from date of first availment of such incentive and
also, I/We give consent to the department that they will take action against us as per
prevailing laws.
1. I/We will have to observe pollution control measures as prescribed by GPCB or other
competent authority.
2. My/Our enterprise will remain in production for at least 7 years from the commencement
of commercial production.
3. I/We will furnish the information regarding the production, sales, turnover, employment
etc. to the DIC annually before the end of September.
4. I/We obtain NOC from Gram Panchayat /Municipal Corporation for doing business, if
applicable.
5. I/We will employ at least 85% of the local employment out of the total employment
provided by the unit and at least 60% of the local employment in supervisory and
managerial employment out of the total employment provided by the unit.
6. I/We am/have not Applied/Granted any subsidy from any other scheme of the State
government or from any other State government agency.

Date: Signature of the Authorised Person

Place: Name of the Authorised Person:
Designation of the Authorised person:
Seal of the Enterprise:
 (For Offline Application)

Application form for Provisional Eligibility Certificate under

Aatmanirbhar Gujarat Scheme for Assistance to MSMEs

(Ref. Government Resolution No. MIS-102022-1271(1)-I dated.05/10/2022)

1. Details of Enterprise
1.1 Name of the Enterprise
1.2 Constitution of Enterprise
(Public Ltd./ Pvt. Ltd./ Partnership
firm / Co-operative society /
proprietorship / Trust)
1.3 Office Address:
Tel. No.
E-mail ID
1.4 Name of Promoters/ Director
Tel. No.
Mobile No.
E-mail ID
1.5 Details of Authorized Person:
Name
Tel. no.
Mobile No.
E-mail ID
1.6 Location of the Project
Survey No./ Plot No.
Village
Taluka
District
1.7 Category of Taluka of the project Cat I / Cat II / Cat III
location
1.8 Project Type New/Existing applying as a
new/Expansion / Diversification
1.9 Udyam Registration/IEM / IL / LOP
No. & Date

1.10 Category of Enterprise as per G.R. Micro/Small/Medium

dated :05/10/2022
1.11 Valid Gujarat Pollution Control Board No.
NOC/consent (If applicable) Date:
Valid up to Date:

1.12 GST Registration No. and Date (for

existing enterprise)

1.13 GST Registration No. and Date (for

Expansion/ Diversification/ existing
applying as a new enterprise) (if
 applicable)

2. Project Details
2.1 Name of Manufacturing Sector
2.2 Date of commencement of
Commercial Production

2.3 Date of Initiation of Expansion or

Diversification (if applicable)

2.4 Whether Commercial Production of Yes / No

Expansion/ Diversification/Existing
applying as New Project
Commenced?
If Yes,
Actual Date of Commencement of
Commercial Production

If No,
Proposed Date of Commencement of
Commercial Production
2.5 Existing Manufacturing Item/s:
No Name of Product Existing Annual Installed Capacity
(with Unit)

2.6 Manufacturing Item/s for New/Expansion/Diversification/Existing Applying as a

new
(Note – In case of Expansion, please mention only proposed additional installed
capacity obtained by Expansion Project)

No. Name of Product Proposed Annual Installed Capacity

(with Unit)

2.7 Project Cost for New Enterprise (Rs. In Lacs)

Sr. No Assets For New
Project or applying as a
new
1. Land
2. Building
Other Construction
3. (Compound Wall, Internal Roads,
Bore well, Water tank etc.)
4. Plant & Machinery
Other Charges for Plant and
5.
Machinery
 Technology, Design and
6.
Drawings, Patents
*Sub Total - 1
Project related Infrastructure
7. (As defined in Para 1.12.D of GR)

Sub Total -2
8. Preliminary and Pre-operative
Expenses
9. Working Capital
10. Other - __________
Sub Total - 3
Grand Total

Project Cost (Expansion/Diversification)

Sr. Assets Existing Gross fixed Project Cost for

No capital investment as Expansion /
on date……….. Diversification
(Before the date of
initiation of Expansion /
Diversification)

11. Land
12. Building
Other Construction
(Compound Wall,
13.
Internal Roads, Bore
well, Water tank etc.)
14. Plant & Machinery
Other Charges for
15.
Plant and Machinery
Technology, Design
16.
and Drawings, Patents
*Sub Total - 1
Project related
Infrastructure
17.
(As defined in Para
1.12.D of GR)
Sub Total -2
18. Preliminary and Pre-
operative Expenses
19. Working Capital
20. Other - __________
Sub Total - 3
Grand Total

*<<The Criteria of Expansion will be calculated on basis of subtotal – 1 only>>

2.8 Means of Finance: (Rs. in Lacs)

Sr. No Particulars Amount

1. Term Loan
2. Promoters’ Contribution
3. Internal Accruals
Others – Please Specify
4.
____________________
Total

2.9 Installed Capacity in case of Expansion:

Name of the Existing Installed Proposed Additional Total Installed

Product Capacity Installed Capacity Capacity
for Expansion
Project

2.10 Details of Utilization of Existing Installed Capacity of previous three years from
the year in which expansion project initiated:

Sr Year Existing Installed Actual % of Actual

No Capacity Production production to
Installed capacity
1
2
3

2.11 Whether the Term Loan for the Proposed Project to Yes / No
Enterprise has been sanctioned?
If Yes, Whether the disbursement of Term Loan incurred? Yes / No
If Yes,

1. Name of Bank and Branch Address, E-mail ID &

Contact No.
2. Term Loan Account Number
3. IFSC Code
4. Date of Sanction of Term Loan
5. Term Loan Sanctioned (Rs. In Lac)
6. Date of First Disbursement of Term Loan
7. Amount of First Disbursement (Rs. In Lac)

Note –

The details to be filled for only First Disbursed Term Loan Account, if Term
Loan is disbursed through multiple bank accounts.
2.12 Whether the applicant/Enterprise has plan to carry out trading Yes / No
activity or any service activity apart from Manufacturing?

If Yes, Whether the applicant/Enterprise has obtained / Yes / No

applied for Separate GST Registration for manufacturing of
Eligible Products only?
2.13 Details of Employment
Existing Employment

Non
Domicile % of Local
Category Domicile Total
Employees Employment
Employees
Manager/ Supervisor
Worker
Total

Proposed Employment

Non
Domicile % of Local
Category Domicile Total
Employees Employment
Employees
Manager/ Supervisor
Worker
Total

Declaration:

I hereby declare that the information, statement & documents submitted are to the best
of my knowledge & belief, true and correct in all particulars. I/We hereby declare that I/
We have read the Government Resolutions MIS-102022-1271(1)-I dated.05/10/2022 and
guideline as amended from time to time before submission of this application for
registration. I/ We undertake to comply all the conditions stipulated therein to avail
incentives mentioned in the resolution.

I/We also hereby state that I/We have not availed any incentive under any other scheme
of Government of Gujarat for the project for which application is submitted.

I/We hereby declare that the details given above are true and correct, if any of the
information is found to be incorrect and not fulfilling the provisions laid down in the
Government Resolution/guideline, registration/incentives are liable to be cancelled.

Place:
Date: Applicant’s signature
Company Seal
Name:
Designation:
 Chartered Accountant Certificate
For
Existing Gross Fixed Investment

(In case of Expansion / Diversification)

((On Letter Head)

This is to certify that the project of M/s.______________ at location (Address

of Project site) and has commenced / proposed to be commencing commercial
production on <date>.

It is hereby certified that M/s …………………………………………… had

incurred following fixed assets at its project site for manufacturing of items
…………………… as on Date ……………

(Rs. In Lacs)

Sr. Assets Existing Gross fixed capital

No investment as on date ………..
(Before the date of initiation of
Expansion)
1. Land
2. Building
Other Construction
(Compound Wall, Internal
3.
Roads, Bore well, Water tank
etc.)
4. Plant & Machinery
Other Charges for Plant and
5.
Machinery
Technology, Design and
6.
Drawings, Patents
Grand Total

We have checked the books of accounts, invoices, balance sheets

etc. of the enterprise and the information is verified and certified true. We
certify that all the aforesaid items have been duly paid and no credit is raised.

Place - Stamp and Sign of

Chartered Accountant
Date – UDIN –
 Chartered Engineer Certificate
For
Utilization of Existing Installed Capacity

(In case of Expansion / Diversification)

((On Letter Head)

This is to certify that M/s. …………………………. located at (Address of

Project site) and manufacturing ……………………. products.

We have visited their Manufacturing Facility for verification and examination of

Machine Manufacturing and Plant Output Capacity. After carefully inspecting
the plant and studying the documents as per our requirement, we certify the
Installed Capacity and Actual Production for last three financial years are as
below –

Sr. Existing Installed Actual % of Actual Production to

Year
No Capacity Production Installed Capacity

1
2
3

Place - Stamp and Sign of

Date - Chartered Engineer
 Undertaking

I ________________________________________ Proprietor / Partner /

Director of M/s. ___________________________________________ project
located at - ____________________________________________________
(Address) hereby solemnly affirm and declare as under with respect to our
application for Registration under Aatmanirbhar Gujarat Scheme for Assistance
to Large Industries and Thrust Sector,

1. I/We have read the Government Resolutions MIS-102022-1271(1)-I

dated.05/10/2022, Guideline and as amended from time to time before
submission of this application for registration. I/ We undertake to comply
all the conditions stipulated therein to avail incentives mentioned in the
resolution.

2. I/We also hereby state that I/We have not applied under any other incentive
scheme of state government or any agency of state government for same
assets for which the application is submitted.

3. I/We also hereby state that there is no outstanding dues / taxes / cess /
charges / fees and its interest and penalty, pending for payment with State
Government, boards and corporation or any agency of State Government.

I/We hereby declare that the details given above are true and correct, if any,
of the information shall found to be incorrect and not according to the provisions
laid down in the Government Resolution/Guideline, the registration certificated
and/or incentives are liable to be cancelled.

For,
M/s. ___________________

Signature
Name
Designation
Company stamp and seal
 (For Offline Application)

APPLICATION FORM
Application for Assistance for Quality Certification
(Aatmanirbhar Gujarat Scheme for assistance to MSMEs)
(Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022)
1. Name of the Enterprise

2. Office Address with pin code No.:

Factory Address with pin code No.:

Tele No.:
Fax No.:
Email Id.:
3. Constitution of the Enterprise
4. Name, address & contact details of the
Promoters
5. Name, designation & contact details of
the Authorized Person
6. Category of Enterprise (Micro, Small,
Medium) As per GR dated 05/10/2022
7. Category of Enterprise (SC/ST/General)

8. Udyam Reg. No./IEM No. / LOI etc

7.1 Manufacturing item
7.2 Annual Production Capacity
7.3 Investment in P&M:
7.4 Date of Production:
9. BIS/WHO/GMP/Hallmark Certification and other National/ International certifications
(excluding ISO Certificate)
1. Name and address of
Certification agency.
2. Name of Quality certification
3. Name of Product/Item for which
QC taken
4. Certificate No. & Date
5. Is this certificate mandatory As
part of statutory provision
6. Certification Agency is
accredited/ notified to provide
this Certificate
10. Details of cost incurred, along with CA
certified statement

Application form Quality certification Page 1of 2

11. Details of any other financial assistance
applied/granted by GOG/GOI
If Yes. Pls give details

12. Bank Details for assistance

Bank Name
Bank Account Name
Bank Account No.
ISFC Code No.
Branch Code No./Branch name
PAN Card No the Enterprise/Applicants
13. Declaration:
I hereby declare that information, statement & documents submitted are to the best of
my knowledge & belief, true and correct in all particulars. I abide with the terms,
conditions, eligibility criteria and parameters specified in the Government Resolutions,
Guideline and as emended from time to time, under the Aatmanirbhar Gujarat Scheme
for assistance to MSMEs. I also declare that
I am authorized by the enterprise to sign and submit then application and related details
with relevant documents.

I/We undertake to comply with the terms, conditions, eligibility criteria, particulars and
parameters of the Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022,
Guideline as amended, and applicable resolutions under Aatmanirbhar Gujarat Scheme for
assistance to MSMEs of Government of Gujarat.

I/We, applying for Assistance for Quality Certification scheme will observe the following
conditions and if I/We will violate these conditions than I/We shall be liable to pay back the
assistance paid and the same will be recovered.
1. I/We confirm that, my/our enterprise is having manufacturing activities.
2. I/We are totally aware that our enterprise will not be eligible for assistance, if any
certification referred in the GR/Guideline, are required as a part of statutory provision.
3. In no case the actual expenditure incurred by my/our enterprise for the said purpose
exceeds the total assistance given by GOG and GOI.
4. I/We are totally aware that expenditure incurred for renewal of certification shall not be
eligible for assistance.

Date: Signature of the Authorized Person:

Place: Name of the Authorized person:
Designation of the Authorized person:
Seal of the Enterprise:

Application form Quality certification Page 2of 2

 (For Offline Application)

APPLICATION FORM
Assistance for Financial Support to MSMEs in ZED Certification
(Aatmanirbhar Gujarat Scheme for assistance to MSMEs)
(Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022)
1. Name of the Enterprise
2. Office Address with pin code No.:

Factory Address with pin code No.:

Tele No.:

Fax No.:
Email Id.:

3. Constitution of the Enterprise

4. Category of Enterprise(General/SC/ST)
Category of Enterprise(New/Existing)
5. Category of Enterprise (Micro, Small and
Medium ) (As per GR Dated 05/10/2022)
6. Pan Card of Enterprise
7. Pan Card of Promoters/Directors/partners
and authorized signatory
8. Name, address & contact details of the
Promoters/Directors/Partners
9 Name, designation & contact details of the
Authorized Person
10 Udyam/IEM/LOI Reg. No
1 Manufacturing item
2 Annual Production Capacity
3 Date of Commencement of commercial
Production(DoCP)
11 For ZED Certifications:
1) Certificate No. & Date
2) Rating Agency :
3) Assistance applied/granted/received
from Government of India for ZED
Certification.
4) Certificate Type(Bronze/Silver/Gold)
12 Details of cost incurred, along with CA
certified statement (Annexure)

13 Details of any other financial assistance

granted by GOG/GOI
If Yes. Pls give details

Application form ZED Certification Page 1of 2

14 Bank Details for assistance
Bank Name
Bank Account Name
Bank Account No.
ISFC Code No.
Branch Code No./Branch Name
15 GST No. of the Enterprise.(if applicable)
16 Declaration:
I hereby declare that information, statement & documents submitted are to the best of my
knowledge & belief, true and correct in all particulars. I abide with the terms, conditions,
eligibility criteria and parameters specified in the Government Resolutions, Guideline and as
emended, under Aatmanirbhar Gujarat Scheme for assistance to MSMEs. I also declare that I
am authorized by the enterprise to sign and submit then application and related details with
relevant documents.

………………………………………………………………………………………………………………………………………………………………

UNDERTAKING

I/We undertake to comply with the terms, conditions, eligibility criteria, particulars and parameters of
the Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022, Guideline and as
amended from time to time, and applicable resolutions under Aatmanirbhar Gujarat Scheme for
assistance to MSMEs of Government of Gujarat.

I/We, applying for Financial Support to MSMEs in ZED Certification scheme will observe the following
conditions and if I/We will violate any condition of GR/Guideline these conditions than I/We shall be
liable to pay back the assistance paid and the same will be recovered.

1. I/We confirm that, my/our enterprise is having manufacturing activities.

2. In no case the actual expenditure incurred by my/our enterprise for the said purpose exceeds
the total assistance given by GOG and GOI.
3. I/We are totally aware that expenditure incurred for renewal of certification shall not be eligible
for assistance.

Date. Signature of the Authorized Person

Place. Name of the Authorized person:
Designation of the Authorized person:
Seal of the Enterprise

Application form ZED Certification Page 2of 2

 (For Offline Application)
APPLICATION FORM
Application Form for Assistance in implementation of Information and Communication Technology (ICT)

(Aatmanirbhar Gujarat Scheme for assistance to MSMEs)

(Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022)
1. Name of the Enterprise

2. Office Address with pin code No.:

Factory Address with pin code No.:

Tele No.:
Fax No.:
Email Id.:
3. Constitution of the
Enterprise(New/Existing)
4. Category of Enterprise (Micro, Small and
Medium ) (As per GR Dated 05/10/2022)
5. Category of Enterprise (General/Sc/ST)
6. Name, address &contact details of the
Promoters/Directors/Partners.
7. Name, designation & contact details of
the Authorized Person
8. Udyam/IEM/LOI Reg. No
1 Manufacturing product
2 Date of Commencement of
commercial Production(DoCP)
9. PAN details of Enterprise,
promoters/Directors/Partners and
authorized signatory
10. ICT System/Equipment details :
1) Name and address of ICT System
equipment/ hardware suppliers
2) Name of Could Provider (if
applicable)
3) List of equipment /hardware with
cost
4) Date of installation of ICT system.
5) Brief description of the cloud/ ICT
system installed.
11. Details of cost incurred, along with CA
certified statement (Annexure)

Application form ICT Page 1of 3

 12. Details of any other financial assistance
applied/granted by GOG/GOI on same
component.
If Yes. Pls give details
13. Bank Name
Bank account name
Bank Account No.
ISFC Code No.
Branch Code No.

14. Declaration:
I hereby declare that information, statement & documents submitted are to the best of
my knowledge & belief, true and correct in all particulars. I abide with the terms,
conditions, eligibility criteria and parameters specified in the Government Resolutions,
Guideline and as emended, under Aatmanirbhar Gujarat Scheme for assistance to MSMEs. I
also declare that I am authorized by the enterprise to sign and submit then application
and related details with relevant documents.

UNDERTAKING
I/We undertake to comply with the terms, conditions, eligibility criteria, particulars and
parameters of the Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022,
Guideline and as amended from time to time, and applicable resolutions under Aatmanirbhar
Gujarat Scheme for assistance to MSMEs of Government of Gujarat.

I/We, applying for Assistance in implementation of Information and Communication Technology

(ICT) scheme will observe the following conditions and if I/We will violate any condition of
GR/Guideline/ these conditions than I/We shall be liable to pay back the assistance paid and the
same will be recovered.
1. I/We confirm that, my/our enterprise is having manufacturing activities.
2. In no case the actual expenditure incurred by my/our enterprise for the said purpose
exceeds the total assistance given by GOG and GOI.

Date. Signature of the Authorized Person

Place. Name of the Authorized person:
Designation of the Authorized person:
Seal of the Enterprise

Application form ICT Page 2of 3

 (For Offline Application)

APPLICATION FORM
Application Form for Assistance for Technology Acquisition
(Aatmanirbhar Gujarat Scheme for assistance to MSMEs)
(Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022)

1. Name of the Enterprise:

2. Office Address with pin code No:
Factory Address with pin code No:
Tele No.: (M)
Fax No.:
Email Id :
3. Constitution of the Enterprise:

Category of Enterprise (Micro, Small and

Medium ) (As per GR Dated 05/10/2022)
4. GST No.(If Applicable)
5. Name, Address & Contact details of the
partners / directors / promoters
(With category General / OBC / SC / ST)
6. Name, Designation & Contact details of the
Authorized Person:
7. Pan No of Enterprise, Promoters, Authorized
Person:
Udyam/IEM/LOI Reg. No :
8. Manufacturing Item Name:
Whether New or Existing?:
Annual Production Capacity:
Annual Turnover:
Date of Commencement of commercial
Production(DoCP)
9. Brief note on technology to be acquired by
Enterprise and how it will be helpful to
enterprise (with technical specification).:
10. Details of Institution, from where technology
is acquired with MOU details.:
11. Patent Grant Details
Patent No/Country.:
Patent grant date. :
12. Royalty percentage /charges to be paid (for
first two years as per agreement):
(If Applicable)
13. Brief Benefits/ Outcome to be obtained by
the enterprise.:
14. Term loan details for technology acquisition
(if applicable)
16. Details of any other financial assistance
applied/ granted by GOG/GOI for technology
acquisition
 17 Bank Details for assistance

Bank Name

Bank Account Name

Bank Account No.
ISFC Code No.

Branch Code No./Branch Name

18. Declaration:
 I hereby declare that the information, statement & documents submitted are to
the best of my knowledge & belief, true and correct in all particulars. I abide with
the terms, conditions, eligibility criteria and parameters specified in the
Government Resolutions, Guideline and as amended, under the Aatmanirbhar
Gujarat Scheme for assistance to MSMEs. I also declare that I am authorized by
the enterprise to sign and submit the application and related details with relevant
documents.

UNDERTAKING

I/We undertake to comply with the terms, conditions, eligibility criteria, particulars and
parameters of the Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022,
Guideline and as amended from time to time, and applicable resolutions under Aatmanirbhar
Gujarat Scheme for assistance to MSMEs of Government of Gujarat.

I/We, applying for Assistance for Technology Acquisition scheme will observe the following
conditions and if I/We will violate any condition of GR/Guideline/ these conditions than I/We
shall be liable to pay back the assistance paid and the same will be recovered.

1. I/We confirm that, my/our enterprise is having manufacturing activities.

2. In no case the actual expenditure incurred by my/our enterprise for the said
purpose exceeds the total assistance given by GOG and GOI.
3. I/We are totally aware that expenditure incurred for renewal of certification shall
not be eligible for assistance.

Date. Signature of the Authorized Person

Place. Name of the Authorized person:
Designation of the Authorized
person: Seal of the Enterprise
 (For Offline Application)

APPLICATION
FORM
Application Form for Assistance for Patent Registration
(Aatmanirbhar Gujarat Scheme for assistance to MSMEs)
(Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022)
1. Name of the Applicant/Individual / Enterprise

2. Office Address with Pin code No:

Factory Address with pin code

No: Cell No. :

Email Id :

3. Constitution of the Legal Entity

(Individual/Proprietorship/ partnership/ company/
society/ others)
4. Category of Enterprise (MICRO/SMALL/MEDIUM)
(As per GR Dated 05/10/2022)
5 Category of Enterprise(New/Existing)
6. Name, address & contact details of the Promoters
/Directors/partners/ Applicant
7. Name, designation, Address & contact details of the
Authorized Person of the legal entity
8. PAN Card No. of Enterprise,
Promoters/Directors/Partners and authorized
signatory
9 Udyam/IEM/LOI Reg. No (not in case of individual)

10 Date of Commencement of commercial

Production(DoCP) (not in case of individual)
11 Type of patent applied/obtained (National /
International )

12. Date of filling application to patent office

13 Title of Patent

Publication Date of National patent application

(attach proof of patent office journal)
Publication Date of International patent application
(attach supporting documents)

1
 Country wise publication Date(attach supporting
documents )
14 Brief description of product/ process for which
patent is applied
15 Application number of National Application

Application number of International Application

16 Name and address of Patent Attorney

Registration No of Patent Attorney

Registration valid up to Date:

17 Total expenditure Claimed (as per Annexure-1)

18 Name of the Bank

Bank Account Name
Bank Account No.
IFSC Code No.
Branch Name/Code
19 Details of any other financial assistance
applied/granted by GOG/GOI (If yes, Provide details)

20 Other information if any

21 Declaration:
I hereby declare that the information, statement & documents submitted are
to the best of my knowledge & belief, true and correct in all particulars. I abide
with the terms, conditions, and eligibility criteria’s and parameters specified in
the Government Resolutions, Guideline and as amended under Aatmanirbhar
Gujarat Scheme for assistance to MSMEs. I also declare that I am authorized
by the enterprise to sign and submit the application and related details
with relevant documents.

2
 UNDERTAKING

I/We undertake to comply with the terms, conditions, eligibility criteria’s, particulars and
parameters of the Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated:
05/10/2022, Guideline and as amended, applicable resolutions under Aatmanirbhar
Gujarat Scheme for assistance to MSMEs.

I/We, applying for Assistance for Patent Registration scheme will observe the following
conditions and if I/We will violate any condition of GR/Guideline these conditions than
I/We shall be liable to pay back the assistance paid and the same will be recovered.

 I/Our Assistance under the scheme will be disbursed to us after the

publication / notification of the patent.
 I/We have submitted the application within one year from the date of
publication/ Notification of the patent.
 I/We are totally aware that the application submitted after one year from the
date of publication / notification will not be eligible for assistance.

Date: Name and Signature of the Authorized Person

Place: Seal of the Enterprise

3
 APPLICATION FORM
Assistance for saving in consumption of Energy and Water (For Offline Application)
(Aatmanirbhar Gujarat Scheme for assistance to MSMEs)
(Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022)

1. Name of the Enterprise

2. Office Address with pin code No:

Factory Address with pin code No:
Tele No. : (M)
Fax No. :
Email ID :
3. Constitution of the Enterprise:

4. Category of the Enterprise(New/Existing):

5. Category of Enterprise (Micro, Small and

Medium ) (As per GR Dated 05/10/2022)
6. Category of Enterprise (General / SC/ST)

7. Name, address & contact details of the

Promoters
8. Name, designation & contact details of
the Authorized Person
9. PAN no of Enterprise
10. PAN numbers of
Promoters/Directors/partners and
authorized signatory
11 Udyam/IEM/LOI Reg. No
1 Manufacturing item
2 Annual Production Capacity
3 Investment in Plant and
Machineries (As per GR)

4 Date of Commencement of
commercial Production(DoCP)

12 Name and address of auditing

institution/consultant/Auditor:
13 Date of Issue of audit Report

14 Details of recognition/ accreditation

received (submit documentary proof)
15 Name of equipment’s used for Energy
/Water Conservation and cost for each
equipment

1
16 Brief of suggestions/ recommendation of
the audit study (submit a copy of Audit
study )
17 Results/ benefits after implementation
of energy/ water saving equipment, i.e.
decrease in consumption of water/
electricity in Nos./ Units/Litters/etc.
18 Details of Audit Expense/Equipment
expense.( CA certified statement in case
of equipment)
19. Details of any other financial assistance
applied/granted by GOG/GOI
If Yes, Provide details
20 Bank Details for assistance

Bank Name

Bank Account Name

Bank Account No.
IFSC Code No.
Branch Code No./Branch Name
21 GPCB approval for CCE/CTE/CCA, (if
applicable)

22 Declaration:
I hereby declare that the information, statement & documents submitted
are to the best of my knowledge & belief, true and correct in all particulars. I
abide with the terms, conditions, eligibility criteria and parameters specified
in the Government Resolutions, Guideline and as amended from time to time
under Aatmanirbhar Gujarat Scheme for assistance to MSMEs. I also declare that
I am authorized by the enterprise to sign and submit the application and
related details with relevant documents.

2
 UNDERTAKING
I/We undertake to comply with the terms, conditions, eligibility criteria, particulars and
parameters of the Government Resolution No. MIS-102022-1271(1)-I(CH)
Dated:05/10/2022, Guideline and as amended, from time to time under Aatmanirbhar
Gujarat Scheme for assistance to MSMEs of Government of Gujarat.

I/We, applying for Assistance for saving in consumption of Energy and Water scheme will
observe the following conditions and if I/We will violate any condition of
GR/Guideline/these conditions than I/We shall be liable to pay back the assistance paid
and the same will be recovered.

1. I/We confirm that, my/our enterprise is having manufacturing activities.

2. I/We are totally aware that our enterprise will not be eligible for assistance, if any
certification referred in the GR, are required as a part of statutory provision.
3. In no case the actual expenditure incurred by my/our enterprise for the said purpose
exceeds the total assistance given by GOG and GOI.
4. I/We are totally aware that expenditure incurred for renewal of certificate shall not be
eligible for assistance.
5. I/WE confirm that energy/water audit conducted by a recognized institution /
consultant.
6. I/We confirm that saving in energy/water minimum by 10% of average monthly
consumption of previous 12 months before audit.

Date: Signature of the Authorized Person

Place: Name of the Authorised person:
Designation of the Authorised person:
Seal of the Enterprise

3
 (For Offline Application)

Application Form

Assistance for raising Capital through SME Exchange

(Aatmanirbhar Gujarat Scheme for assistance to MSMEs)
(Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022)

Name and address of Enterprise :

(i) Name of Enterprise:
1 (ii) Location Address of Enterprise:
(iii) Telephone No. / Mobile No.:
(iv) E-Mail ID:
2 Constitution of Enterprise(New/Existing) :
3 Category of Enterprise (Micro, Small and
Medium ) (As per GR Dated 05/10/2022)
4. Category of Enterprise (General / SC/ST)
Authorized person/Director Details :
(i) Name :
5 (ii) Telephone No. / Mobile No.:
(iii) Email ID :
(iv) Address :
Registered Office Address.
6 Location of Manufacturing Plant/units/Service
outlet in Gujarat
7 Udyam/IEM/LOI Reg. No and Date.
Date of Commencement of commercial Production(DoCP)
8 Details of registration with Exchange:
1) Date of Listing in SME Exchange
(NSE/BSE/others):
2) Date of Capital Issue Published:
3) Issue open Date :
4) Issue Close Date :
9 GST Registration No.:

10 Item of Production/service:
11 Name & Address of Registrar of Capital Issue of the
Enterprise:
12 Name & Address of merchant Banker of Capital
Issue of the Enterprise:
13 Detail of capital issued arranged:
(I) Total Amount of Equity Capital for which Capital Issue Arranged:
(II) Amount of Equity Capital raised out of that.:
 14 Gross Investment in P/M as on listing date value
15 Head wise details of Expenditure incurred for
raising of fund through SME Exchange :
Paid Expenditure:
Un Paid Expenditure:
Total:
16 Is the project in commercial production after the
listing?
(i) If Yes Date of Commercial production after
listing Date.
(ii) IF no than Expected date of commencement
of Production.
17 GPCB approval for CCA (if applicable):
18 Whether any other assistance obtained in any
other scheme of Government of Gujarat / GOI /
Others. for the same component?
19 Bank details of Enterprise :
Name & Address of Bank:
Bank A/c Name:
Bank A/c Number:
IFSC Code:
Branch Name/Code:
Declaration:
I hereby declare that information, statement & documents submitted are to the best of my knowledge
& belief, true and correct in all particulars. I abide with the terms, conditions, eligibility criteria and
parameters specified in the Government Resolutions, Guideline and as emended, under Aatmanirbhar
Gujarat Scheme for assistance to MSMEs. I also declare that I am authorized by the enterprise to sign
and submit then application and related details with relevant documents.

UNDERTAKING

I/We undertake to comply with the terms, conditions, eligibility criteria, particulars and parameters of the
Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022, Guideline and as amended from
time to time, and applicable resolutions under Aatmanirbhar Gujarat Scheme for assistance to MSMEs of
Government of Gujarat.
I/We, applying for Assistance for raising Capital through SME Exchange scheme will observe the following
conditions and if I/We will violate any condition of GR/ Guideline these conditions than I/We shall be liable to
pay back the assistance paid and the same will be recovered.
1. I/We confirm that, my/our enterprise is having manufacturing activities.
2. In no case the actual expenditure incurred by my/our enterprise for the said purpose exceeds the total
assistance given by GOG and GOI.

Date. Signature of the Authorized Person

Place. Name of the Authorized person:
Designation of the Authorized person:
Seal of the Enterprise
 (For Offline Application)

APPLICATION FORM
Assistance for Power Connection Charges
(Aatmanirbhar Gujarat Scheme for assistance to MSMEs)
(Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022)
1. Name of the Enterprise
2. Office Address with pin code No.:
Factory Address with pin code No.:Tele
No.:
Fax No.:
Email Id.:
3. Constitution of the Enterprise
4. Category of the
Enterprise(General/SC/ST ):
5. Category of Enterprise(New/Existing)

6. Category of the Enterprise(Micro,

Small and Medium ) (As per GR Dated
05/10/2022)
7. Name, address , contact details of the
Promoter
8. Name, designation & contact details
of the Authorized Person
9. PAN details of Enterprise
10. PAN details of promoters and
Authorized Signatory
11 Udyam/IEM/LOI Reg. No
1 Manufacturing Product:
2 Investment in P&M:
3 Date of Commencement of commercial
Production(DoCP)
11 (A) Unit details :
1) Location: GIDC/Approved Industrial Park
area/outside GIDC or outside of Ind.
Park approved under
industrial policy.
2) Connection: New/additional Load/
Shifting of Connection or line:
(B) Motive Power Details:
1) Name of Power supplying Co. &
Consumer No. whether HT or LT
connection
(2) Sanctioned Load HP/KW:
(3) Connected load HP/KW:

Application form power connection charges

 (4) Service Line Charges:
Bill No., Date, Amount of bill, date of
Payment
(5) Power Connection Charges:
Bill No.: Date Amount of bill, Date of
Payment
12. Details of any other financial
assistance applied/granted by
GOG/GOI
If Yes. Pls give details
13. Bank Details for assistance
Bank name
Bank Account name
Bank Account No.
IFSC Code No.
Branch Code No/Branch name.
14 Declaration:
I hereby declare that information, statement & documents submitted are to the best
of my knowledge & belief, true and correct in all particulars. I abide with the terms,
conditions, eligibility criteria and parameters specified in the Government
Resolutions, Guideline and as emended from time to time, under the Aatmanirbhar
Gujarat Scheme for assistance to MSMEs. I also declare that I am authorized by the
enterprise to sign and submit then application and related details with relevant
documents

UNDERTAKING

I/We undertake to comply with the terms, conditions, eligibility criteria, particulars and
parameters of the Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022,
Guideline and as amended from time to time under Aatmanirbhar Gujarat Scheme for
assistance to MSMEs of Government of Gujarat.
I/We, applying for Assistance for Power Connection Charges scheme will observe the following
conditions and if I/We will violate any condition of GR/Guideline these conditions than I/We
shall be liable to pay back the assistance paid and the same will be recovered.
1. I/We confirm that, my/our enterprise is having manufacturing activities.
2. In no case the actual expenditure incurred by my/our enterprise for the said purpose
exceeds the total assistance given by GOG and GOI.

Date: Signature of the Authorized Person

Place: Name of the Authorized person:
Designation of the Authorized person:
Seal of the Enterprise

Application form power connection charges

 (For Offline Application)

APPLICATION FORM
Assistance in Rent to Micro & Small Enterprises (MSEs)
(Aatmanirbhar Gujarat Scheme for assistance to MSMEs)
(Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022)

1. Name of the Enterprise

2. Office Address with pin code No.:

Unit Address with pin code No.:

Tele No.:
Fax No.:
Email Id.:
3. Constitution of the Enterprise
4. Category of Enterprise MICRO/SMALL/MEDIUM
(As per GR Dated 05/10/2022)
5. Category of Enterprise GEN/SC/ST
Category of Enterprise( New/Existing)
6. Name, address & contact details of
the Promoters
7. PAN Card no. of Enterprise,
promoters/Directors/Partners and
authorized signatory
8. Name, designation & contact details
of the Authorized Person
9. Udyam/IEM/LOI Reg. No

1 Manufacturing Product:
2 Investment in P&M:
3 Date of Commencement of
commercial Production(DoCP)
10 Property/Premises/Shed Details
(A) Owners details :
1) Name of Owners:
2) Address Details of owner :
3) Contact no.:
4)PAN/Aadhar No.
(B) Rent Details:
1) Rent agreement/deed date.:
(2) Period of rent agreement/deed:
(3) Period of Rent:
(4) Monthly amount of Rent:
5) Monthly amount of Rent excluding
1
 GST
6) Is the rented building having Yes/No
industrial power connection?
If yes
(i) Meter No.
(ii) Distribution company name
If No
Have you applied for
power connection?
Application date.: Distribution
company name
11. Details of any other financial
assistance applied/granted by
GOG/GOI
If Yes. Pls give details
12. Bank Name
Bank Account Name
Bank Account No.
IFSC Code No.
Branch Code No.
Branch Name/code
13. Other Information (if any)

14. Declaration:
I hereby declare that information, statement & documents submitted are to the
best of my knowledge & belief, true and correct in all particulars. I abide with the
terms, conditions, eligibility criteria and parameters specified in the Government
Resolutions, Guideline and as emended from time to time, under Aatmanirbhar
Gujarat Scheme for assistance to MSMEs. I also declare that I am authorized by the
enterprise to sign and submit then application and related details with relevant
documents.

2
 UNDERTAKING
I/We undertake to comply with the terms, conditions, eligibility criteria, particulars and
parameters of the Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022 as
amended, Guideline and applicable resolutions under Aatmanirbhar Gujarat Scheme for
assistance to MSMEs of Government of Gujarat.
I/We, applying for Assistance for rent assistance scheme will observe the following conditions
and if I/We will violate any conditions of GR /Guideline/these conditions than I/We shall be
liable to pay back the assistance paid and the same will be recovered.
1. I/We confirm that, my/our enterprise is having manufacturing activities.
2. In no case the actual expenditure incurred by our enterprise for the said purpose
exceeds the total assistance given by GOG and GOI.
3. We have taken all required statutory approvals/NOC/permission.

Date. Signature of the Authorized Person

Place. Name of the Authorized person:
Designation of the Authorized person:
Seal of the Enterprise

3
 (For Offline Application)
APPLICATION FORM
Application Form for Assistance for Enterprise Resource Planning (ERP Assistance)

(Aatmanirbhar Gujarat Scheme for assistance to MSMEs)

(Government Resolution No. MIS-102022- 1271(1)- I(CH) Dated: 05/10/2022)
1. Name of the Enterprise

2. Office Address with pin code No.:

Enterprise/Factory Address with pin code

No.:

Tele No.:
Fax No.:
Email Id.:
3. Constitution of the Enterprise
4. Category of Enterprise (General / SC/ST)
5. Category of Enterprise (New/Existing)
6. Category of Enterprise (Micro, Small and
Medium) (As per GR Dated 05/10/2022)
7. Name, address & contact details of the
Promoter/Directors/Partners
8. Name, designation & contact details of
the Authorized Person
9. PAN card number of the Enterprise
10 PAN card number of
promoters/Directors/Partners and
authorized signatory.
11 Udyam/IEM/LOI Reg. No
1 Manufacturing item
2 Investment in P&M:
3 Date of Commencement of commercial
Production(DoCP)
12. (A) ERP System :
1) Name and address of ERP System
/Module supplier
2) Detailed features of the ERP
system/Module installed.
3) Date of installation of ERP system.

13 Details of cost incurred, along with CA

certified statement

Application form ERP Assistance Page 1of 2

14 Details of any other financial assistance
Applied/granted by GOG/GOI on same
component.
If Yes. Provide details
15. Bank Details for assistance
Bank Name
Bank Account Name
Bank Account No.
ISFC Code No.
Branch Code No./Branch Name
16. Declaration:
I hereby declare that information, statement & documents submitted are to the
best of my knowledge & belief, true and correct in all particulars. I abide with the
terms, conditions, eligibility criteria and parameters specified in the Government
Resolutions, Guideline and as emended from time to time, under Aatmanirbhar
Gujarat Scheme for assistance to MSMEs. I also declare that I am authorized by the
enterprise to sign and submit then application and related details with relevant
documents.

I/We undertake to comply with the terms, conditions, eligibility criteria, particulars and
parameters of the Government Resolution No. MIS-102022-1271(1)-I(CH) Dated:05/10/2022,
Guideline and as amended from time to time, and applicable resolutions under Aatmanirbhar
Gujarat Scheme for assistance to MSMEs of Government of Gujarat.
I/We, applying for Assistance for Enterprise Resource Planning (ERP)Assistance scheme will
observe the following conditions and if I/We will violate any condition of GR/Guideline/these
conditions than I/We shall be liable to pay back the assistance paid and the same will be
recovered.
1. I/We confirm that, my/our enterprise is having manufacturing activities.
2. In no case the actual expenditure incurred by my/our enterprise for the said purpose
exceeds the total assistance given by GOG and GOI.

Date: Signature of the Authorized Person

Place: Name of the Authorized person:
Designation of the Authorized person:
Seal of the Enterprise

Application form ERP Assistance Page 2of 2