1. (a) Name and address of the unit
   [Office & Factory Location (s).]
   (b) Telephone No. Factory & Office
   (c) E-mail & Fax
   
2. Details of E.M. No.
   date of issue; Directorate of Industries/
   GM, DIC of the State concerned
   (Enclose an attested copy of all pages
   of E.M.No. Certificate to be enclosed)
   
3. Wheather SC/ST
   
4. Wheather Women Enterpreneurship
   
5. Item (s) of manufacture/processing
   as indicated in the E.M.Certificate.
   
6. Proof of SSI status and functional status of the unit
   as on the date of submission of Application
   The following document(s) to be submitted
   1. A certificate (in original) from State DI/GM,DIC
      confirming SSI and functional status of the unit
      at the time of acquiring ISO-9000/ ISO-14001 certificate;
      as on date as per Format at Annexure I.
      OR
   2. An Affidavit (in original) from Managing Director/
      Director/Proprietor/Partner of the SSI unit duly sworn
      before a Notary Public confirming SSI status and functional
      status of the unit at the time of acquiring ISO-9000/ISO-14001
      certificate; and as on date,( As per Format Annexure II)
      accompanied by CA certificate of the total investment in
      plant & machinery as on date (original purchase value)
      (As per Format Annexure III)

    

7. Details of ISO-9000/ISO-14001 Certificate
   Name and address of Certification agency; The Certificate
   must have address of the site/location certified; Scope
   of certification, Certificate No , date of issue &
   period of validity (or date of expiry), Name & Logo
   & Number of the Accreditation Body/Board.
   (Enclose an attested copy of the Certificate)
   
8. Details of expenditure incurred in acquiring ISO-9000/ ISO-14001
   Certificate (excluding hotel & travel expenses & surveillance charges).
   Furnish a CA certificate of expenditure (in original)
   giving the details (as per the Format Annexure IV).
   
9. Details of reimbursement/grant/subsidy
   already received, if any, from Centre Govt (including DC(SSI) /
   State Govt./Financial Institution etc. for acquiring ISO-9000/
   ISO-14001Certificate ( Furnish, an Undertaking/declaration
   (in original) from the Managing Director/Director/
   Proprietor/ Partner of the SSI/ ancillary units duly sworn before
   Notary Public (as per the Format Annexure V)
   
10. Pre-receipt to be furnished as per Format at Annexure VI.

Declaration:

Name and Signature of Managing Director/
Director/Proprietor/Partner of SSI unit.
(Full Name)

(1)GM (DIC) or (2) Director, SISI of the Region or (3) Chartered Accountant (with name of the signatory, CA Stamp, and CA Membership No. )

Annexure 'I'

CERTIFICATE

This is to certify that M/s-------------------------------------------------------- With their office at -------------------------------------------------------------- & factory located at --------------------------------------------------------------------------- with E.M.No.----------------------------------------------- dated---------------is an SSI/Tiny/SSS BE unit as per Govt. of India definition and has been functional & in production at the time of acquiring ISO-9000/ISO-14001 Certification No---------------------dated-------------------and also continues to be functional & in production as on date.

Dated

Director of Industries/
GM (DIC)
Name & Rubber Seal

Annexure 'II'

AFFIDAVIT**

I,-------------------------------------------------------s/o-------------------------------------- Managing Director/Director/Proprietor/Partner,* M/s.------------------------------------------- ---------------------with their Regd. Office at -------------------------------- & Factory located at--------------------------------------------------------------- with E.M. No.-------------------------------------------dt.--------------- do hereby solemnly affirm and declare as under:

1. The Company/Firm/Establishment has been a SSI/ancillary/Tiny/SSSBE* unit as per the Govt. of India definition; and has been functional & in production at the time of acquiring ISO-9000/ISO-14001* certification No.------------------------dated-------------
   
   
2. The Company/Firm/Establishment continues to be a SSI/ancillary/Tiny/SSSBE unit; and functional & in production as on date.
   
   
3. As per books of account, the total investment (original purchase value) in plant and machinery in the Company/Firm/Establishment as on ----------------------is Rs-----------------------------------------(Chartered Accountant Certificate dated----------------to this effect is attached).

Signed on this day of-------------------------dt----------------------

DEPONENT

VERIFICATION:
I do solemnly affirm that the contents of the Affidavit are true to the best of my knowledge & belief.

DEPONENT

Date:

Place:

(Note) * Strike out whichever is not applicable.

**On a Stamp paper (of Rs.10/- min) in Delhi /amount as applicable in the respective State duly sworn before a Notary Public( duly affixed with Notarial Stamp; and with Notary Seal; and Notary Registration number) or First Class Magistrate

Annexure ''III''

Certificate from Chartered Accountant about investment in Plant & Machinery (on C.A. Letter Head)

To Whom It May Concern

Verified from the Books of Accounts of M/s._____________________________________with their Regd. Office at ________________________________________________ and Factory located at _________________________________and E.M. No._________________________dt. ________________that the total investment in plant and machinery (original purchase value) of the company as on date*_________________ stands as Rs.__________________________(Rupees____________________________ _________________________________________________________)

Name & Signature of the
Chartered Accountant with stamp
and Membership number.

Place:

Date:

* Date of Application or 31st March of Preceding financial year.

Annexure''IV''

Certificate from Chartered Accountant in respect of Proof of Expenditure incurred for acquiring ISO-9000/ISO-14001
(on a C.A Letter Head)

To Whom It May Concern

The documents & records of M/s._______________________________________with their
Regd. office at __________________________________________and factory located at
__________________________________________________and E.M.
No.__________________________ dt. _________________)

in respect of the expenditure incurred by them in acquiring ISO-9000/ISO-14001 Certificate (or its equivalent) have been verified; and it is certified that the said company have incurred a total expenditure of Rs._____________ (Rupees _____________________ ____________________________________) towards ; Application fee; Assessment/Audit fee; Annual fee/Licence fee; Training; Calibration; and Technical Consultancy etc. (excluding hotel & travel expenses & Surveillance charges) in obtaining ISO-9000 /14001 from the Certification Agency namely_________________________________; as per the following details of payments:

Details of Payments (Name of Certification Agency/Orgn.) Amount paid(in Rupees)

* a) Application Fee paid to ------------------
* b) Assessment/Audit Fee paid to ---------------------
* c) Annual Fee/Licence Fee paid to ---------------------
d) Calibration charges paid to----------------------------
e) Technical Consultancy charges paid to-------------------
f) Training expenses paid to----------------------------------

Total -----------------------------------

Place----------------

(Signature of the Chartered Accountant
with Name CA Stamp & CA
Membership Number)

Dated--------------

* Payments at (a),(b) & (c) above should be supported by copies of receipts of payments made to the Certification agency duly attested. The payment receipts must indicate the purpose for which the payments have been made to the Certification Agency.

Note: Payments made to the Certification agency directly shall only be eligible for consideration of reimbursement.

Annexure ''V''

To be submitted by the Applicant on a Non-judicial Stamp paper of Rs. 50/-(Min) in Delhi /amount as applicable in the respective State duly sworn before a Notary Public (duly affixed with Notarial Stamp; and with Notary Seal & Notary Registration number) or First Class Magistrate

UNDERTAKING/ DECLARATION

I,-------------------------s/o---------------------Managing Director/Director/Proprietor/Partner, M/s.------------------------------with Regd. office at--------------------------- & factory located at-------------------------------------------------and with E.M. No.---------dt.--------------- do hereby solemnly affirm and declare as under:

(a) (i) That the aforesaid Company/Firm/Establishment(s) have not availed reimbursement/subsidy/grant/incentive for acquiring, ISO 9000/ISO-14001 Certification under any Scheme operated by Central Govt. (including o/o DCSSI, M/o SSI)./ State Govt./ Financial Institution etc.

OR

(a) (ii) That the aforesaid Company/Firm/Establishment(s) have claimed & received reimbursement/subsidy/ grant/incentive for acquiring ISO 9000/ISO-14001 Certification amounting to Rs__________ (Rupees __________ from _____________(Name of the Central Govt/State Govt Deptt./Financial Institution vide draft/cheque No-----------dt---------- of------------(Name of Bank).

(b) (i) That the aforesaid Company/Firm/Establishment(s) have already applied to--------Name of the Central Govt (other than O/o DCSSI)/ State Govt/ Financial Institution ) vide application dated--------for reimbursement/ subsidy/ grant/incentive for acquiring ISO- 9000/ISO-14001 Certification .

OR

(b) (ii) That the aforesaid Company/Firm/Establishment(s) have not applied to any Central Govt./State Govt./ Financial Institution (except o/o DC(SSI), Ministry of SSI), for reimbursement/subsidy/grant/incentive, for acquiring ISO-9000/ISO-14000 Certification.

( c) That after availing reimbursement for ISO-9000/14001/HACCP Certification from Office of DC(SSI), Ministry of SSI, in respect of the said Company/Firm/Establishment(s), I shall disclose this fact on behalf of the said Company/Firm/Establishment(s) at the time of claiming/ receiving reimbursement/ subsidy/grant/incentive, if any, under any other similar scheme run by Central Govt./State Govt. /Financial Institutions etc..

(d) I hereby solemnly affirm that the information given above is correct. In case above declaration is found wrong or incorrect or misleading, I do hereby bind myself & my unit and undertake to pay to the Government on demand the full amount received as reimbursement in respect of above mentioned activity, within seven days of the demand being made to me in writing.

Partner/Proprietor/ Managing Director/ Director

In the presence of:

1. (Full Name and addresses of the two witnesses also to be indicated along with signatures)

Note: The factual status as on date under the respective paras at (a); (b) & (c) above must be clearly indicated

Annexure ''VI''

Name of the Industry : ____________________________
Address : ____________________________
____________________________
____________________________
Phone Number : ____________________________

PRE - RECEIPT (in Triplicate)

Received a sum of Rs.__________________(Rupees ____________ ________________________________________) from the Development Commissioner (Small Scale Industries) towards the reimbursement of expenses incurred for obtaining International Quality Certification ISO - 9001 / ISO - 14001. .

Rubber Stamp of the Unit

*Signature of the Authorized Person (on Revenue Stamp)

(B) FOR OFFICE USE ONLY

Passed for the payment for Rs.__________________(Rupees_________________ _____________________________________) Vide sanction No._____________ ______________dated_________________.

Asstt. Director

Office of the Development Commissioner (SSI)

Nirman Bhavan, New Delhi - 110 011.

Note: Please read the instructions on pre-page carefully before filling this Annexure VI i.e. Pre-Receipt.

INSTRUCTIONS

Note: - Please follow the following instructions while Preparing this Annexure VI given in next page.

1. Please ensure you prepare the Annexure VI in A-4 size paper only.
2. Please ensure you give Annexure VI in triplicate.
3. Please type the name of your industry, full address and telephone numbers as indicated in the sample format, in the portion marked A.
4. Please do not fill in the amount in the pre-receipt. Leave the portion blank. The office of DC (SSI) will fill it up after calculating the amount due to you.
5. Please ensure the authorized person of your unit signs at the places indicated for signatures of the authorized person on revenue stamp.
6. Please type portion 'B'' yourself in the A-4 size paper as indicated in the format.
7. Office of the DC (SSI) will fill up the amount and the sanction no. in the spaces provided for the same.
8. The Assistant Director concerned will sign at the place earmarked for his signature.

The format is also available at O/o DC(MSME) Website: http://www.laghu-udyog.com/ or http://www.smallindustryindia.com/ or http://www.dcmsme.gov.in/ .

Note:

1. Application complete in all respects alongwith the required documents shall enable reimbursement expeditiously.
2. For any further guidance/details, the enquiries may be sent at the above address.
3. Application Format & its Enclosures can be downloaded from the above Website.