In Association with Indian Industries Association, Kanpur Organizes

MSME- Development Institute, Kanpur in association with Indian Industries Association, Kanpur organizes “ NATIONAL VENDOR DEVELOPMENT PROGRAMME CUM-INDUSTRIAL EXHIBITION” STALL BOOKING FORM

Venue: IIA Premise, Udyog Kunj,Panki Site-V, Kanpur Date: 1 & 2nd March,2017 Sr. No.------1 Name of the organisation 2 Address

3 Name of Properitor/Director Mr./Mrs/Ms.

4 Social Status of Properitor/Director General/ Minority/ Women /PH/SC&ST (Please tick)

5 Phone Nos. (Moblie / land line)

6 E-mail ID

7 Enterprise category Micro / Small / Medium / Large / PSUs (Please tick) UAM No. /EM-II/SSI Regn. No.:

9 Nature of Activity Manufacturing / Service

10 Products Mfg. /Services rendered

11 Octanorm Stall  Stall Charges: MSEs - Rs. 4000/- Size: 3.0 Mtr. x 2.5 Mtr.  Medium Unit- Rs. 6,000/-, Large unit /CPSUs- Rs. 10,000/- (Note: 50% stall charge for SC/ST, Women & PH owned MSMEs) 12 No. of Stalls required 0ne /two / three (pl. tick)

13 Other requirments like Extra Power load, Aditional space for publicity 14 Payment Mode : Digital payment(through NEFT) : In the A/c of Director MSME-DI, Kanpur, Account No. : 30607241548, IFSC No. : SBIN0000219 Branch code : 219, Branch : SBI Industrial Estate Fazalganj, Kanpur Demand Draft : In favour of Director MSME-DI, Kanpur, D.D./ Multicity Cheque No: ………………………… Date:------/02/2017, Amt. Rs. ------16 Signature with date

------MSME-Development Institute, Kanpur (Receipt)

Received with thanks from M/s ------, Amt. Rs. ------(through (NEFT/DD/ Multicity Cheque no.------) on -----/02/2017 against the advt. to publish in souvenir / booking of stall in NVDP-cum Industrial Exhibition on 1 &2nd March, 2017 at IIA, Bhawan, Kanpur.

Date: Signature with seal of officer Name: Name of the organisation M/s Address

Name of Properitor/Director Mr./Mrs/Ms. Social Status of Properitor (Gen./ Minority/ Women /PH/SC/ST) Moblie & E-mail ID

Enterprise category (Please Tick) Micro / Small / Medium / Large / PSUs UAM No. /EM-II/SSI Regn. No.: Nature of Activity (Please Tick) Manufacturing / Service Products Mfg./Services renderd Octanorm Stall Stall Charges: MSEs UnitRs.4000/- Size- 3.0 Mtr. x 2.5 Mtr  Medium Unit- Rs. 6,000/-,  Large unit /CPSUs- Rs. 10,000/- 50% Stall Charges for SC/ST, Women & PH owned MSMEs Payment Mode : Digital payment(through NEFT) in A/c of Director MSMEDI, Kanpur, A/c No. 30607241548, IFSC No. SBIN0000219, Branch code : 219, Branch : SBI Industrial Estate, Fazalganj, Kanpur Demand Draft : In favour of Director MSME-DI, Kanpur,  D.D. No: ………………………… Date: ------/------/2017, Amt. Rs. ------