| a) Name of the Organisation |
: ______________________________ |
| b) Address |
: ______________________________ |
| c) State |
: ______________________________ |
| d) District |
: ______________________________ |
| e) Block |
: ______________________________ |
| f) Phone No. (With STD Code) |
: ______________________________ |
| g) Fax No .(if any) |
: ______________________________ |
| h) Nearest Railway Station |
: ______________________________ |
| i) Registration NO. of the Organisation |
: ______________________________ |
| j) Date of Registration |
: ______________________________ |
| k) Date of Renewal, if any |
: ______________________________ |
| l) Area of Operation |
|
| I) As per Memorandum of Association (MOA)
|
: ______________________________ |
| II) For implementation of this programme |
: ______________________________ |
| m) Name and branch of the Bank from where the NGO
operates: |
: ______________________________ |
| n) Account No. |
: ______________________________ |
| o) Name and Designation of Chief Functionary |
: ______________________________ |