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)

 

 

 

 

 

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 from all sources

(1)

(2)

(3)

(4)

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

2

 2

 

 

 

 

 

 

 

 

3

 3

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 (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.

 

 

 

 

 

 

 

 

 

 

 

 *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 I    

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.

 

 

 

 

 

 

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  Total

 

 

 

 

 

 

 

 

 

 

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

 

 

 d.         Details regarding

 

          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

 

 

2.

Attested copy of MOA & Bye-laws

 

 

3.

Indicate the provision to borrow from outside agency

 

 

4.

Detailed Objectives of the Organization

 

 

5.

Details of Bio-data of the Chief Functionary experience in social sector

 

 

6.

List of current Managing Committee members duly attested

 

 

7.

Resolution for seeking credit assistance from RMK

 

 

8.

Consolidated audited accounts for the last 3 years

 

 

9

Annual Reports for the last 3 years

 

 

10

Copies of sanctions received from funding agencies/Govt. Departments etc

 

 

11.

Utilisation certificate received for funding agencies

 

 

12.

Undertaking to charge rate of interest not more than 18% NGO to SHG to ultimately beneficiary on reducing balance

 

 

13.

Undertaking to keep the registration of the organization alive during the currency of RMK loan

 

 

14.

Undertaking that office bearers should not be elected members of any political party

 

 

15.

Undertaking to inform RMK in case of changing address.

 

 

16.

If borrowed from other organizations, No Dues / Overdues certificate from funding agencies

 

 

17.

Details of Socio-Economic development activities implemented during the last 2/3 years 

 

 

18.

Passport size photographs of the President, Secretary & Treasurer of the organization duly attested by a Gazetted Officer each photo to be attested individually.

 

 

19.

Certificate regarding proof of residence of the President, Secretary and Treasurer with their present and permanent address duly attested by a Gazetted Officer

 

 

20.

Details of arrangements available for organizing training for its Staff/SHGs

 

 

21.

Copy of resolution in case of dissolution of the organisation / Undertaking Rs. 50/- for dissolution clause

 

 

22.

Clause of 2/3rd quorum in MOA byelaws.

 

 

23.

DCB for the last three years

 

 

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