RASHTRIYA MAHILA KOSH
1, Abul Fazal Road, New Delhi - 110001
APPLICATION
FORM
FOR FRANCHISEE SCHEME
1.
Name of
the organisation
2.
Address
3.
Phone No.,
Fax No, Email
4.
Nearest
Railway Station
5.
Registration
No. of the organization
6.
Date of
register /Date of renewal
7.
Area of
operation
8.
As per MOA
9.
For
implementation of Progress
10.
Name of
the Bank of the organization and Account No.
11.
Name &
Designation of the Chief Functionary
12. Details of Executive Committee members
|
S.No. |
Name |
W/o or D/o or S/o |
Designation |
Address with Door no. / Street / Village / Town / District |
Land
line no. / Mobile no. |
|
(1) |
(2) |
(3) |
(4) |
(5) |
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Note: Please enclose a copy of your annual reports of last three years
For office use only:
13. Experience of the organisation in CREDIT Activity during last three years
a) Internal loaning of SHGs promoted
b) Directly funding by the NGO to SHG
c) Indirect experience in credit (As a facilitator for Bank / other funding Agencies)
d) Loan given to any NGOs
(year wise). (Amount in Rs.)
|
Years |
No. of SHGs |
No. of Borrowers |
Amount of loan disbursed |
|
(1) |
(2) |
(3) |
(4) |
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14.
FORMAT
OF DEMAND COLLECTION AND BLANCE REGISTER (DCB)
Loaning
made to SHG members out of their own savings (Inter loaning)
Loaning
made to SHGs out of the funds received from funding agencies.
Loaning
made to SHGs from Bank where NGO acts as a facilitator.
Loaning
made to SHGs out of own funds of NGO.
YEAR WISE (Last three years)
| SL. No. |
NAME
OF SHG |
Amt.
of loan outstanding from previous year (31.3. -- |
Amt.
of loan disbursed during the year |
Total =3+4 |
Demand
amount , which was due for recovery as on ---- |
Amount
actually recovered as on -- |
Over
due as on ----- (6-7) |
Percentage
of recovery (%) |
Outstanding
at the end of the year 31.3.-- (5-7) |
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| 1 |
1 |
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| 2 |
2 |
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| 3 |
3 |
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Separate
DCB statement for A, B, C, D, category has to be submitted by the NGO (year wise
and SHG wise for last 3 years).
It
should be tallied with other related statements/information furnished by the
NGO, any.
“Nil”
statement may be submitted regarding A or B or C or D if the NGO does not have
any experience in under such category.
Note:- The details in S.No. 14 should tally with the books of SHGs and with the data maintained by NGO
15.
Experience
of the organization in thrift/savings and internal loaning as on 31st
March______
a) NGOs
b) SHGs
|
SN. |
Name
And Address of SHG |
Date
of Formation |
No.
of Members |
Savings
Mobilized (Cumulative) |
Loans
Given Out of Savings (Cumulative) |
Amount
Outstanding |
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(Separate sheet may be attached)
Note:- The details in S.No. 14 should tally with the books of SHGs and with the data maintained by NGO
16.
Proposed lending programme in the current year (For other NGOs only)
|
Name
of the NGO |
Address |
Date
of Regn. |
Exp.
In Micro Credit |
Total
SHGs formed |
Total
savings |
Total
internal lending |
Loans
from other agencies |
Rate
of recovery |
Amt.
Of loan required |
Total fund
recd. From other funding agencies/track record. |
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*Details
of NGO profile, activities undertaken may be enclosed with the proposal.
17.
Financial position of the organization for last 3 years:
a.
Liabilities
Assets
Year
II
Separate sheet may be attached.
Year
III
b.
Borrowing if any: as on 31st March…….
|
Name
of the lending institution |
Date
of loan |
Amount
of loan |
Amount
repaid |
Overdue |
Balance
Outstanding. |
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Separate
sheet may be attached.
(Copies of Sanction letters to be enclosed)
c.
Financial details of NGOs to whom
loan would be provided by Franchisee.
|
Name of the
NGO |
LIABILITIES |
ASSETS |
||||||
|
|
Capital |
Surplus/Deficit |
Loans |
Others
Total |
Fixed |
Current |
Loans |
Others |
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18. Organisational set up:
a.
No. of trained staff
No. of untrained staff
b.
Trained staff:
Details regarding training programme attended, name of the trainer, name of the
training institution.
N.B. Please attach Xerox
copies of certificate of each trained staff.
c.
Other infrastructure:
a.
Training
material/programme
b.
Training
hall
c.
Resource
persons
d.
Computer
and other equipment
e.
Vehicle
Bio-data of all staff and MC members and nodal officers.
e.
Experience
if any as a nodal agency/mother NGO/FRANCHISEE of any other funding
organization.
19. Check List
|
S.N. |
Details
of Enclosures |
Yes/No |
Page
No. |
|
1. |
Attested
Copy of the Registration Certificate/Renewal |
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2. |
Attested
copy of MOA & Bye-laws |
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3. |
Indicate
the provision to borrow from outside agency |
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4. |
Detailed
Objectives of the Organization |
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5. |
Details
of Bio-data of the Chief Functionary experience in social sector |
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6. |
List
of current Managing Committee members duly attested |
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7. |
Resolution
for seeking credit assistance from RMK |
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8. |
Consolidated
audited accounts for the last 3 years |
|
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9 |
Annual
Reports for the last 3 years |
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10 |
Copies
of sanctions received from funding agencies/Govt. Departments etc |
|
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11. |
Utilisation
certificate received for funding agencies |
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12. |
Undertaking
to charge rate of interest not more than 18% NGO to SHG to ultimately
beneficiary on reducing balance |
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13. |
Undertaking
to keep the registration of the organization alive during the currency of
RMK loan |
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14. |
Undertaking
that office bearers should not be elected members of any political party |
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15. |
Undertaking to inform RMK in case of changing address. |
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16. |
If borrowed from other organizations, No Dues / Overdues certificate from funding agencies |
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17. |
Details
of Socio-Economic development activities implemented during the last 2/3
years |
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18. |
Passport
size photographs of the President, Secretary & Treasurer of the
organization duly attested by a Gazetted Officer each photo to be attested
individually. |
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19. |
Certificate
regarding proof of residence of the President, Secretary and Treasurer
with their present and permanent address duly attested by a Gazetted
Officer |
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20. |
Details
of arrangements available for organizing training for its Staff/SHGs |
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21. |
Copy
of resolution in case of dissolution of the organisation |
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22. |
Clause
of 2/3rd quorum in MOA byelaws. |
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23. |
DCB
for the last three years |
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DECLARATION
I________________________(Full Name with Designation) certify that the facts and figures furnished in the application form and the annexures are correct and tally with the records of our Organisation and any concealment of facts/misrepresentation/indulgence in illegitimate practices which are violative of the terms of sanction and as a consequence thereof, the Rashtriya Mahila Kosh is put to monetary loss, will render me liable to be proceeded against under the relevant provisions of the law of the land.
Place:
Date:
(Signature with official stamp)
Encl.:
Name & Designation of
chief Executive