Note : Application received in an incomplete form or after the prescribed date will not be entertained

1. Name of Organisation/Institution   _____________________________________________

2. Brief history of organisation/institution and description of its objects and activities.

    _______________________________________________________________________

    _______________________________________________________________________

    ________________________________________________________________________

3. Whether recognised by the State Government _______________________________

4.Whether the organisation/institution is registered under Indian Societies Registration Act, 1860 (Act XXI of 1860) or corresponding State Acts, or it is managed by a Trust or Body of Trustees. (Details of registration with the Name of Act)

   ________________________________________________________________________

5.Whether the organisation/institution is managed by Central Government/ State Govt. or Local Body

  _________________________________________________________________________

6.Whether the organisation/institution is of All-India Character. If so, give the nature of its All India activities.

_________________________________________________________________________

7.Whether organisation/institution has already a hostel if so, whether in its own or a rented building starting number of inmates.

  _________________________________________________________________________

8.Number of working women for whom hostel is intended to be constructed and also the number of the pre-school children for whom the Day-Care-Centre is proposed.

  __________________________________________________________________________

9.Likely date of commencement and completion of hostel building.

    __________________________________________________________________________

10.Whether the project is likely to be assisted by some other official or non-official agency. If so, their name and  the extent of assistance proposed to be provided by each may be indicated.

    __________________________________________________________________________

    __________________________________________________________________________

11.Justification of the project indicating the Outstanding features which entitle it to Central Assistance.

    _________________________________________________________________________

12.(a)Total estimated expenditure on the Project  _____________________________________

(b)Amount of grant required from the Government of India _______________________________

(c)Source(s) from which the balance expenditure is proposed to be met

  _________________________________________________________________________

  __________________________________________________________________________

13.Whether necessary land for the proposed building is available if so, give details in India (location and area) with evidence for ownership.

  _________________________________________________________________________

  _________________________________________________________________________

14. (a)Details of plinth area to be constructed in relation to the number of working women for whom construction to be undertaken including number of rooms with capacity , number of floors toilets and common facilities

  ________________________________________________________________________

  _________________________________________________________________________

(b)Whether plinth area is according to the standard laid down by the State Govt./local Admn. for similar projects.

  ________________________________________________________________________

(c)Whether trained staff and other suitable facilities for undertaking construction are available, if so, give details.

  ________________________________________________________________________

15. Whether the institution/organisation is in a position to meet the balance expenditure, If so, indicate the source (s)

  ________________________________________________________________________

16. List of papers/statements to be attached

(a) Prospectus of the voluntary organisation/institution of a brief description of its objects and activities;

(b) Constitution of the Organisation/Institution ;

(c) Constitution of the Board of Management and the particulars of each member ;

(d) Copy of the latest available Annual Report ;

(e) Detailed structural Financial estimates of the hostel building, giving item-wise details of recurring and non-recurring expenditure and the sources from which the remaining funds will be obtained;

(f) Information relating to the grant received from promised by or the requests made to other bodies,, e.g. State Governments, Local Bodies, etc. for the construction of  the proposed  hostel building. The decisions of these bodies on such requests would be communicated to them.

(g) A statement of the full receipts and expenditure of the voluntary organisation/institution for the last two years and a copy of the balance sheet for the previous year certified by authorised Auditors/Chartered Accountant ;

(h) A copy of site-plan of the proposed hostel building with a certificate from the local municipal authorities that the construction of the building has been permitted;

(i) A certificate to the effect that the rates of construction to be adopted are not in excess of the Scheduled of rates of the PWD of the State concerned duly countersigned by the Head of the State PWD concerned or its nominee ;

(j) Documentary proof of ownership of plot on which the hostel is proposed to be constructed.

17. List of additional papers., if any

18. Additional information, if any

(Signature)

(Name in Block Letters)

Date Designation

Office Stamp

The application from------------------------------- is forwarded duly recommended to the Department of Women & Child Development, Government of India with the following comments :

(i) that a senior officer of the-------------------------- Department has visited the institution/organisation with a copy of his report is attached;

(ii) that the institution/organisation is recognised and/or registered under the Indian Societies Registration Act 1860 or corresponding State Act/Public Trust (give numbers),

(iii)that the application has been examined and that it is found to be covered under the scheme;

(iv) that the hostel building for which the application is being recommended is absolutely essential in the area for the following reasons----------------------------------------------------------------------------------------------------------

(v) that there is a minimum of 25 working women in the area;

(vi) that its work in the field of welfare of women/social welfare/women's education has been reported as satisfactory during the last three years;

(vii) that the organisation/institution is not run for profit to any individual or a body of individuals;

(viii)That the organisation/institution does not charge capitation or other similar fees from inmates of other states;

(ix) that the land for the construction of hostel building is available. The locality is good and respectable.

(x) that the accomodation proposed to be constructed and rates of the proposed construction conform to the standards laid down by the State Government;

(xi) that assistance has/has not given by the State Govt. In the former case, details of the assistance sanctioned during the last five years for the purpose may be given

(xii) that the organisation/institution is on a sound financial position; and

(xiii) the organisation/institution has facilities, resources, personnel and experience to initiate construction of the hostel building and the balance expenditure will be met by the organisation/institution or by the State Government.

2.The State Government/Union Territory Administration recommend that the grant for Rs.--------------- may be sanctioned to the organisation/ institution by the Ministry of Human Resource Development, Department of Women & Child Development for the construction of the hostel building.

(Signature)

(Name in Block Letters)

Date Designation

Office Stamp

Note : The officer signing this certificate should be of above the rank of an Under Secretary to the State Government/ Union Territory Administration.