PM Vishwakarma
(Registration Form)
Personal Details
Full Name Father/Spouse Name Date Of Birth
Bhavani Akash 01-01-2003
Marital Status Gender Category
Married Female SC
Divyangjan Business in same state?
No Yes
Business in same district? Minority?
Yes No
Contact Details
Mobile No. Aadhaar No. PAN Card
7760714227 XXXXXXXX1214 N.A.
Family Details
Ration Card No.
N.A.
Name Relationship Aadhaar No.
akash HUSBAND xxxxxxxx7645
Aadhaar Address
Aadhaar Address
C/o: C/O: Akash Loc: Sedam vtc: Surwar Subdist: Sedam Street: Surwar State: Karnataka po: Sedam pc: 585222 dist: Kalaburagi Country:
India
State District Pin code
KARNATAKA KALABURAGI 585222
Do you Come under Gram Panchayat?
Yes
Block Gram Panchayat
SEDAM TELKUR
Current Address
Current Address
C/o: C/O: Akash Loc: Sedam vtc: Surwar Subdist: Sedam Street: Surwar State: Karnataka po: Sedam pc: 585222 dist: Kalaburagi Country:
India
State District Pin code
KARNATAKA KALABURAGI 585222
Do you Come under Gram Panchayat?
Yes
Block Gram Panchayat
N.A. N.A.
Profession/ Trade Details
Profession / Trade Name
Sub Category
Tailor (Darzi)
Business Address
C/o: C/O: Akash Loc: Sedam vtc: Surwar Subdist: Sedam Street: Surwar State: Karnataka po: Sedam pc: 585222 dist: Kalaburagi Country:
India
Business State Business District
KARNATAKA KALABURAGI
Saving Bank Details
Name of Bank IFSC Code Name of Branch
State Bank of India sbin0020235 SEDAM
Account No. Confirm Account No.
XXXXXXXXXXXXXX2442 41890032442
Credit Support
Do you want Credit Support? Loan Amount Required (1st Tranche) Preferred Bank to Take Loan
Yes 100000 State Bank of India
Preferred Branch to Take Loan Loan Purpose Purchase of Equipments
SEDAM Yes Yes
Working Capital / Operating Expanses Business Expansion Outstanding Amount (in Rs.)
Yes Yes 30000
Existing Loan Monthly EMI Amount (in Rs.) Total Monthly Family Income (in Rs.)
State Bank of India 3000 40000
Digital Incentive Details
Are you Digitally Active? UPI ID UPI ID Linked Mobile Number
No N.A. N.A.
Skill Training
You are eligible for skill training for below training programes.
Basic (5 Days) Skill Training
Advance (15 Days) Skill Training
Tool Kit
Once you are registered and skill training certified you will be given a grant of ₹15,000
Marketing Support
Marketing Support question that applies to your business expansion
Onboard your product/ service on E- Commerce platform
Quality Certification Required
Participate in Exhibitions and Trade Fairs
Logistics support Required
Brand Building Support Required
Declaration Details
Declaration and Authorization
1. I hereby declare that I am engaged in the trade as indicated in the application form.
2. I hereby declare that apart from myself, no other member of my family has registered for PM Vishwakarma and that no
member of my family is in government service.
3. I have no objection to authenticate my Aadhaar number, share the same with other Ministries / Departments under the
Government of India or the State Government for the purpose of extension of benefits under any of their Schemes, carry out
e-KYC and accessing my credit history & credit score from credit bureau by the lenders and their authorized agents. The
consent and purpose of collecting Aadhaar has been explained to me in local language. MoMSME/Lending Institution has
informed me that my Aadhaar submitted herewith shall not be used for any purpose other than mentioned above, or as per
requirements of law. I have been informed that this consent and my Aadhaar will be stored along with my account details
with MoMSME or their authorised agent as per the extant law.
4. I hereby agree that my application may also be processed for availing Udyam Assist Certification which will enable me for
Priority Sector Lending (PSL) benefits.
5. I hereby declare that information given above is true to the best of my knowledge. I am well aware of the fact that, if the
information given by me is proved false/not true, I will be liable for action as per the law. Also, all benefits shall be summarily
withdrawn.
Date : 20/02/2024 Signature of Applicant(s)
Place : KALABURAGI
