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APPLICATION FORM FOR EMPANELMENT OF ORGANISATION

APPLICATION FORM FOR EMPANELMENT OF ORGANISATION
01 Name of the Organisation *
02 Type of Organisation *
03 Registered Address * Upload Address Proof (For SHGs- Address Proof of the Group Leader (Only PDF max 80 KB)
Address Line 1 *
Address Line 2
District * Block *
Municipality/ Panchayat * Village/ Town *
PIN Code *
04 Correspondence Address * Same as Registered Address
Address Line 1
Address Line 2
District * Block *
Municipality/ Panchayat * Village/ Town *
PIN Code *
05 Mobile No. *
06 Alternate Mobile No.
07 Email ID *
08 Brief Description of the Organisation * Within 300 Words
09 Vision & Mission Document of the Organisation Upload Copy (Only PDF max 80 KB)
10 Organisational Structure Upload Copy (Only PDF max 80 KB)
11 Year of Establishment *
12 Date of Registration/ Establishment/ Incorporation *
13 Type of Registration Document *
ADD Upload Copy (Only PDF max 80 KB)
14 PAN No. * Upload Copy (Only PDF max 80 KB)
15 TAN Upload Copy (Only PDF max 80 KB)
16 GSTIN Upload Copy (Only PDF max 80 KB)
17 UDYAM Registration No. Upload Copy (Only PDF max 80 KB)
18 MoA/ Deed of Trust/ Partnership Deed/ Bye Law of the Organisation (Full Document) * Upload Copy (Only PDF max 200 KB)
19 Details of the Head of the Organisation / Highest Authority of the Organisation *
Name Photo Upload Copy (Only JPG max 50 KB) Designation Attach Aadhaar Card Upload Copy (Only PDF max 80 KB) ADD
20 Bank Account Details *
Name of the account holder Account Number IFSC Code Branch Name
21 Upload Bank Account Details * Upload Scan of the Cheque of the Bank Account in the name of the organisation/ For SHGs – Scan of the 1st Page of the Passbook (Only PDF max 80 KB)
22 Audit & Accounts Documents * Income Tax Return (Last 1 Year) [Mandatory for all except SHG] Applying as SHG Upload Copy (Only PDF max 200 KB)
Audited Balance Sheet & P/L – Last 1 Year [Mandatory for all except SHG] Upload Copy (Only PDF max 200 KB)
For SHGs- Scan of the Statement of the Savings/ Flexi Account of Last 6 Months (Only PDF max 200 KB)
23 Accreditation [Max 5 Nos.]
ADD Upload Copy (Only PDF max 200 KB)
24 Recognition/ Empanelment/ Affiliation/ Collaboration [Max 5 Nos.]
ADD Upload Certificate (Only PDF max 200 KB) ADD
25 TRAINER DETAILS- as per the Prescribed Format * Upload Copy (MS Excel max 50 KB)
26 AVAILABLE INFRASTRUCTURE DETAILS – as per Prescribed Format * Upload Copy (MS Excel max 50 KB)
27 Work Order / Completion Certificate of Training Programmes conducted under Govt. Organisations/ reputed Non-Govt. Organisations in last 3 years
Upload Certificate (Only PDF max 200 KB) [Max 3 Nos.] ADD
28 Awards / Accolades (If any) Within 300 Words
29 Photos of Training Programmes/ Awards Received
Upload Certificate (Only PDF max 200 KB) [Max 3 Nos.] ADD
30 Transaction Details* Upload Copy (Only PDF max 80 KB)
Transaction No.*
Date of Transaction*
Amount of Transaction*
From Bank*
31 Any other Related Information Within 200 Words
32 SELECT DISTRICTS AND TRADES APPLYING FOR EMPANELMENT *
 
ADD Select Trades (Maximum 20)
33 Date Place * Signature * Upload Copy (Only JPG max 50 KB)
Declaration (Organisation)
We hereby declare that –
1. The information furnished above are true to best of our knowledge.
2. We would strictly abide by the Terms & Conditions stated in the “Expression of Interest” and deliver the services as required with optimum sincerity.
3. We have not been barred/ banned/ restricted from any such services from any Govt. or Non-Govt. Organisations in the past.
4. We have a clean legal background and no Criminal Case has been filed against me in the Court of Law as per our knowledge.
5. We are able to serve as a Training Provider for both short and long duration Programmes of the selected trades in the Urban and Rural Areas of the selected District/s of West Bengal along with all types of Machineries, Equipments and Training Material support as and when required.
6. We are capable of providing Marketing and Network building Support temporarily for the Target groups of Trainees.