FORM – WB-I

IMPORTANT : Please fill up this form furnishing correct details sought for, based on verifiable true state of affairs without causing suppression of any material information which, if resorted to, shall entail prosecution under the relevant laws.

1. Name and full postal address                                                 :
    of the applicant.

2. Status of applicant                                                                 :
    (whether Consumer Activist/
    Women’s Organisation/
    Voluntary Consumer Organisation/
    NGO)

3. Date of Establishment                                                             :

4. Whether registered under the                                                  :
    relevant Act or Law

5. If yes, number and year of                                                       :
    registration (attested copy of
    registration certificate to be enclosed)

6. Whether the Organisation is                                                     : 
    of State/District/Sub-Division/
    Block/Village level

7. Number of Managing Committee                                             :
    members together with list of names,
    addresses and occupations of the office bearers

8. Brief details of the organization                                                :
    objectives and activities during the last three years

9. Purpose for which the amount                                                 :
    is required (please state the details of
    the project and its proposed implementation)

10. Amount of grant required (item-                                            :
      wise details under non-recurring/
      recurring to be enclosed)

11. Time schedule of the                                                             :
      activities arranged

12. The total amount incurred/                                                     :
      invested by the applicant, or likely
      to be incurred by the applicant

13. Sources of funding of the balance                                           :
      amount. Whether the organization is getting
      financial assistance from any official/non-official source.
      If yes, give details.

14. Details of prosecution if any,                                                   :
      in a Court of Law, launched against the applicant,
      during the last five years.

15. Copies of the following documents                                          :
      (duly attached by a gazetted officer of the
      Central or State Government) to be attached

                              i) Constitution of the organization
                                 and Articles of Association

                              ii) Annual reports of the organization 
                                 for last three years (please furnish separate
                                 Annual Reports for each year)

                              iii) Annual Audited Statement of accounts
                                  for each of last 3 years duly signed by
                                  Chartered Accountant. These Statements must 
                                  bear the registration number and official seal
                                  of stamp of the Chartered Accountant.

                              iv) Registration Certificate of the Organisation.

                              v) List of Members

DECLARATION

         The particulars heretofore given are true and correct. Nothing material has been suppressed.It is certified that I/We have read the guidelines, terms and conditions governing the Scheme and undertake to abide by them on behalf of our Organization/Institution. The financial assistance, if provided, shall be out to the declared use, for promotion and protection of the rights of consumers or for purposes relating thereto. I/We have signed this declaration after fully understanding the covenants of the Scheme.

Dated:
Place:

APPLICANT

To
Member Secretary
Committee (State Consumer Welfare Fund)
11A, Mirza Ghalib Street
Kolkata – 700 087

Recommendation of Member-Secretary

          Factual details furnished in the application have been verified in consultation with Ministry/Department or agency who is/are administratively concerned in the matter and found to be correct/incorrect. The claims of the applicant are recommended for consideration by the Committee (Please give reasons in support of your recommendation).

Member-Secretary
Committee(State Consumer Welfare Fund)

Recommendation of the Committee

Recommended for grant of Rs. …………………………..………..
(Rupees ……………………………………………………………………………………………………) only
from the State Consumer Welfare Fund as discussed in the meetings held on …………..…………..

Chairman/Member Secretary

(To be typed on non-judicial stamp paper of Rs.10/- and duly attested by a Notary Public)

AFFIDAVIT

I, _______________________S/o D/o W/o __________________________resident of _____________ and presently
working as President/Secretary of M/s__________________________________________ do hereby solemnly declare
and affirm under :-
That M/s (name and full address of the organization) have received the following
grants-in-aid from Ministries/Departments/Organizations during the last three years :-

Year:

Name of funding Ministry/organization:

Amount of grant received:

Purpose of grant:

Sanction letter No. and date:

Deponent

Verification

Verified that the above information is complete and true to the best of my knowledge and belief
and nothing has been concealed there from. I also accept that if the information furnished hereby is found to be
incomplete or incorrect, the grant from consumer Welfare Fund may be cancelled.

Verified this the __________________ day of _______________ in the year Two Thousand
and _______________.

Deponent

Witnesses :

1.
2.