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1. Name of firm/company : ____________________________________

2. Address Regd office :

For correspondence :

Factory :
(if outsourced, attach details)

3. Type of business : Sole Proprietorship/Partnership/Pvt. Ltd / Public Ltd/

Govt. Undertaking/other
4. Status of supplier : Manufacturer/Brand Owner/Ex-Servicemen/Importer
5. Annual turnover : ________ __________ _______
(last three years)
6. Registration number : CST ________ VAT ________
Income Tax _______________
7. Product offered :

Sl. Brand Item Description & Year Market Exports Warranty
No & Model No. of Launch in Share if any Period
Civil Market
Units Value

8. Price of products offered :

Sl Item MRP Ex-factory ED applicable in Net Rate to CSD Max Net Rate
No. price % and as (inclusive of discount to CSD
assessable value Excise Duty & to CSD after
Exclusive of Sale discount
Tax/VAT & Local

9. Whether item offered has been applied & : Yes/No

rejected in last 3 years
10. If offered items are on contract list of : Yes/No (If yes, attach details)
DGS & D or any other Govt. Authority
11. Is firm a SSI unit : Yes/No
12. Has firm been blacklisted by : Yes/No (If yes, attach details)
State/Central Govt.
13. Are products BIS approved : Yes/No (If yes, attach details)
14. NUMBER OF ITEMS APPLIED -_________________________
BANK NAME - _______________________ AMOUNT PAID - _______________
UTR NO.- _______________________ DATE OF TRANSACTION -__ ________


It is certified that information rendered in the application form & enclosures is correct to the
best of my/our knowledge. In case of any incorrect information rendered/deviations found
thereto at a later stage which may adversely affect the departments interest, it will be the
manufacture/ suppliers responsibility and the item will become liable for deletion and firm will
be black listed.

Signature of supplier/
Person authorised _____________________

Name: ______________________________

Designation: _________________________

Date: ________________
Name of Firm: ________________________