GOLD CARD SCHEME FOR EXPORTERS
APPLICATION FORM FOR WORKING CAPITAL CREDIT FACILITIES
________________________________________________________________________

1.1 Name of the Unit
(In block letters)

1.2
Constitution
Please strike out which are not applicable
Proprietary/Partnership Firm/Private Limited/ Public Limited Company/Co-operative Society
1.3 Name of the business
house/group (of any )

2.1

2.2
Registration No.
(as given by the District
Industries Centre/Directorate
of Industries)
IEC No.
2.3 Date of Incorporation/
Commencement of Business

3.
Business Address with Telephone/Telex No.
3.1 Registered Office

3.2 Administrative Office

3.3

3.4 Factory

Email address / Website

4. Background of the Proprietor/Partners/Directors
(Please furnish for each person as per the Annexure I)

5. Brief Description of the
Industrial Activity

5.1 Existing

5.2 Proposed

.
6.How the Activity was financed so far
(to be filled up in case of existing unit only)

Source of Funds
(*) Security Rate of Intt. Repayment per Month in case of Term Loans only Present O/S (in 000s
Of Rs.) Amount of OD
(if any)

(*) Indicate sources of funds with name & address, e.g. banks/financial Institutions/others (specify)

7. Past Performance
(To be filled up by existing unit only)
(Indicate in 000s of Rs.)
Particulars Last Year Last but One Year Last but Two Years
Turnover
Net Profit
Retained Profit
Major Countries to which exports made

Monthly Turnover for last twelve months

8. Arrears in Statutory Payments ( if any)

9. Whether Merchant Exporter or
Manufacturer Exporter

10. Name of the associate concern(s),
if any, and

10.1
Nature of association and
amount invested

10.2 Nature of activity

10.3 Items traded manufactured

10.4 Turnover and profit
during preceding three years

11. Technical Feasibility - required only in case of a new unit (As per Annexure IV)

12. ECONOMIC FEASIBILITY
Marketing (mention separately for each product)

12.1
Countries where the product is/will be sold

12.2
How does the unit meets/proposes
to meet the competition
(comment on the competitive
advantages enjoyed by the unit)

12.3
Is the unit selling direct to
its customers. If so, please furnish
details like sales force,
showrooms, depots,
warehouses, offices abroad.
12.4 Nature and volume of orders/
enquiries on hand
(certified xerox copies to be furnished)

13. Future Projections
(To be given for the next three years)
Please furnish data on
13.1 Projected balance sheet as per Annexure III
13.2 Working Capital Requirement as per CMA Data
14. Financial Assistance Required
14.1 Rupee Loan
14.2 Foreign Currency Loan
14.3. Non-Fund Based Limits, i.e.
other Forms of assistance
(e.g. L/Cs. Bank Guarantees, etc).
15. Details of Securities to be Offered :
15.1 Primary
15.2 Collateral (full details), if any

15.3
Details of guarantor(s)
(Names & addresses), if any

16 Please indicate whether
The proprietor/any of
The partners/promoters/
Directors have at any time
Declared themselves as insolvent.
If so, details thereof.

17.
Whether the Proprietor/
Partner/Directors/Guarantors
Are related to any official
of the Bank. If yes, then
details thereof

I/We certify that all information furnished by me/us is true; that I/We have no borrowing arrangements for the unit with any Bank except as indicated in the application; that there is no overdues/statutory dues against me./us /promoters except as indicated in the application; that no legal action has been/is being taken against me/us/promoters that I /We shall furnish all other information that may be required by you in connection with my/our application; that this may also be exchanged by you with any agency you may deem fit; and you, your representatives, representatives of the Reserve Bank of India/national Bank of Agriculture & Rural Development/Small Development Bank of India/Deposit Insurance & Credit Guarantee Corporation / ECGC / EXIM Bank / CIBIL or any other agency as authorised by you, may, at any time, inspect/verify my/our assets, books of accounts. etc, in our factory/business premises as given above.

Date:

Place: _______________________

Signature of the Borrower
(Name & Designation)

Encl: Certified Xerox copies of
a) Audited Balance sheets with Trade and Profit & Loss Account, for the last three years, and next three years with CMA data,
b) Memorandum and Articles of Association, Certificate for Commencement of Business
c) Income Tax, Wealth Tax Returns and assessment orders for the last three years, for the unit as well as proprietor/partners/promoters/directors
d) Sales Tax Returns for the last three years.
e) Pollution Clearance Certificate