PM Vishwakarma
(Registration Form)
Personal Details
Full Name Father/Spouse Name Date Of Birth
Sandhyarani Jena Bichitrananda Jena 01-01-1996
Marital Status Gender Category
Married Female General
Divyangjan Business in same state?
No Yes
Business in same district? Minority?
Yes No
Contact Details
Mobile No. Aadhaar No. PAN Card
7205334124 XXXXXXXX6486 N.A.
Family Details
Ration Card No.
07101111631
Name Relationship Aadhaar No.
SOUMYARANJAN JENA SELF xxxxxxxxxxxx
Sandhyarani Jena SELF xxxxxxxxxxxx
Aadhaar Address
Aadhaar Address
C/o: C/O: Bichitrananda Jena House: AT/PO-KRUSHNAPRASAD Loc: NIALI vtc: Krushnaprasad Subdist: Niali State: Odisha po: Krushnaprasad pc: 754004 dist: Cuttack
Country: India
State District Pin code
ODISHA CUTTACK 754004
Do you Come under Gram Panchayat?
Yes
Block Gram Panchayat
NIALI KRUSHNAPRASAD
Current Address
Current Address
C/o: C/O: Bichitrananda Jena House: AT/PO-KRUSHNAPRASAD Loc: NIALI vtc: Krushnaprasad Subdist: Niali State: Odisha po: Krushnaprasad pc: 754004 dist: Cuttack
Country: India
State District Pin code
ODISHA CUTTACK 754004
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: Bichitrananda Jena House: AT/PO-KRUSHNAPRASAD Loc: NIALI vtc: Krushnaprasad Subdist: Niali State: Odisha po: Krushnaprasad pc: 754004 dist: Cuttack
Country: India
Business State Business District
ODISHA CUTTACK
Saving Bank Details
Name of Bank IFSC Code Name of Branch
Indian Bank IDIB000N026 NIALI
Account No. Confirm Account No.
XXXXXXXXXXXXXX9777 6578699777
Credit Support
Do you want Credit Support? Loan Amount Required (1st Tranche) Preferred Bank to Take Loan
No 0 N.A.
Preferred Branch to Take Loan Loan Purpose Purchase of Equipments
N.A. No No
Working Capital / Operating Expanses Business Expansion Outstanding Amount (in Rs.)
No No N.A.
Existing Loan Monthly EMI Amount (in Rs.) Total Monthly Family Income (in Rs.)
N.A. N.A. N.A.
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 : 10/03/2024 Signature of Applicant(s)
Place : CUTTACK
