Gujarat Chamber of Commerce & Industry GCCI MSME Excellence Awards Application Form

Transcription

1 1) Enterprise Category Gujarat Chamber of Commerce & Industry GCCI MSME Excellence Awards Application Form Micro Enterprise (Original Investment in Plant & Machinery not exceeding 25 lakhs) Small Enterprise (Original Investment in Plant & Machinery between 25 lakhs and 5 crores) Medium Enterprise (Original Investment in Plant & Machinery between 5 crores and 10 crores) 2) Basic Information Name of the Company Name of the CEO/MD/Proprietor/Head/Partner of the Company Address of the Factory Unit Contact Details of the Company Address

2 Phone Fax Website Year of Establishment: Your company is: Private Ltd. Public Ltd. Partnership Proprietorship Number of Employees ( ) a. Permanent: b. Contractual: Industry Segment: Textiles (including Technical Textiles, Cotton Ginning & Pressing, Readymade Garments) Chemicals, Dyes and Intermediaries (including Petrochemicals, Paints, Mineral based Products, and Lubricating Oils) Ceramics and Glass Pharmaceuticals (including Bulk Drug & Formulations) Agro Products and Food Processing (including Cold Storage) Engineering and Automobiles (including Foundries, Steel Fabrication and Textile Machineries) Plastic and Rubber Industry Electrical and Electronic Goods IT and ITES (including IT Services ITES, Hardware, Software, KPO, BPO)

3 Others (including Wooden, Leather, Handicrafts, and all the remaining sectors) If Others, Please specify your segment: Number of years in operation: Less than 5 8 to 10 5 to 7 More than 10 Is your company rated by any Rating Agency? If yes in the above Question, please specify a) Rating: b) Rating Agency: 3) CSR and Innovation Initiatives (As applicable) What is your spend on CSR Initiatives as a %age of turnover? 0 % 1% 2% 3% More than 3% What is your spend on R&D Initiatives as a %age of turnover? 0 % 2% 1% 3% More than 3% Have you taken steps for Pollution Control? (If yes, please enclose

4 Have you taken any measures for Energy Conservation? (If yes, please enclose Have you taken adequate Safety measures? (If yes, please enclose Have you taken any measures for Environment Conservation/ Waste Management/ Afforestation/ Greenhouse Mitigation? (If yes, please enclose 4) Standardization & Quality Control (As Applicable) Accreditations obtained for Standardization & Quality Control: (If yes, please enclose ISO-9000/ISO-14000/18000/22000 Certification/ HACCP/GMP/Equivalent Certificate BIS Mark/Equivalent Products conform to IS or any other National/International/User standards 5) Financial Performance Details of Investment (Rs. In Lakhs) Gross Block i. Land ii. Building iii. Plant & Machinery (original) iv. CSR and Innovation v. R&D Initiatives

5 vi. Pollution Control vii. Energy Conservation viii. Others Total Gross Block (i+ii+iii+iv+v+vi+vii+viii) Turnover (Rs. In Lakhs) Domestic Turnover (Rs. In Lakhs) Export Turnover (Rs. In Lakhs) Total Turnover (i+ii) (Rs. In Lakhs) Profit Before Tax Net Worth Total Production Quantity 6) Bankers Details Name of the Banker Address of the Banker 1) 2) 3) 4) 7) Any other important Achievement/ Award: (Please enclose

6 Declaration: I/We shall be abiding by the decision of the Committee for granting of Award. I/We undertake to refund the cash price, return the trophy and certificate, if awarded to me, in case it is ever found that the information furnished above was incorrect. Further, I/We may also be liable for any action under the law of land for any false declaration. I/We hereby affirm and declare that the information furnished in this form is authentic and correct. I/We hereby declare that the information, statement and other papers given herein are true and correct to the best of my knowledge and belief. I/We also declare that I/We am duly authorized to sign an application and also to submit details and documents. te: All Financial Statements to be submitted by the Enterprise must be signed by the Authorized Signatory of the Enterprise and certified by the Auditor/Charted Accountant. Date: Signature of the Applicant Or Authorized Signatory Place: With Name & Designation Seal of the Unit

7 Check list of Annexures Check list of documents/write-ups to be submitted along with prescribed Application Form with the documentary evidence for the awards to best MSMEs. Sr.. Particulars Please tick wherever applicable 1 Copy of EM Part- II. 2 Copy of Constitution of Enterprise CA Certified Details of Annual Production Capacity, Investment, Production, Sales, Export-Profit and Employment of Last five years. Copy of valid GPCB consent or copy of circular, if applicable. CA Certified Audited Annual Account Financial Statements (Balance Sheet & Profit & Loss Account) of Last five years. 6 Details of State/National Level Award received earlier. 7 Details of Important Achievements. 8 Details of Environment Conservation. 9 Details of Safety Measures. 10 Details of Energy Conservation. 11 Details of Quality Certifications: ISO/BIS etc. 12 Whether the Entrepreneur belongs to SC/ST, If attach certificate of Competent Authority. 13 Justification/ Write up - For why the Unit should be awarded. Signature of the Applicant Or Authorized Signatory With Name & Designation Seal of the Unit