APPLICATION FORM FOR MSMEs

To be submitted along with documents as per the checklist

(For Office Use)

1 NAME OF THE B.P BHAGAT MEMORIAL HOSPITAL & DIAGONOSTIC

ENTERPRISE CENTRE PVT. LTD.

2 REGD. OFFICE OLD ELECTRICITY OFFICE BUILDING, BAGDOGRA,

ADDRESS: DIST- DARJELING

3 ADDRESS OF
- DO-
FACTORY/ SHOP:

4 PREMISES OWNED/RENTED/
OWNED
LEASED

Telephone No. 9734223128

(Office) Email Address [email protected]
Mobile No. 9434045256 om
PAN Card No AAECB1709Q

5 CONSTITUTION: Individual/Joint/Prop. Concern/ Partnership firm/ Pvt. Ltd/

Ltd. Company/ Trust/ Others

UDYAM-WB-06-0005156
6 UDYOG AADHAR NO/
REGISTRATION NO

6. GST REGISTRATION NO 19AAECB1709Q1ZB , REGISTRATION DT.- 13-03-2023

A & DATE OF
REGISTERATION

REGISTRATION ON
NO
 6. GEM (YES / NO), IF YES
B THEN REGISTERATION
NO

06-07-2010
7 DATE OF
ESTABLISHMENT
/INCORPORATION WEST BENGAL
8
STATE
DARJEELING
9
CITY / DISTRICT
WHERE LOAN IS HILL CART ROAD BR., SILIGURI
10 REQUIRED

BRANCH WHERE LOAN

IS REQUIRED, If Any

11 NAME OF THE PROPRIETOR/ PARTNERS/ DIRECTORS OF COMPANY AND THEIR

ADDRESSES:
S. Name Date Father / Academic Category Mobile No.
N of Spouse Qualification SC/ST/OBC/
o Birth s Minority/Women
1. Ranjit 23-08- Sarayu MBBS, DCH, NA 9434045256
Bhagat 1969 Prasad PGDI- ECO
Bhagat CARDIO
2. Gourav 16-10- Tarak MBBS, DIP IN NA
Bhagat 1997 Nath DNB IN ENT
Bhagat
3. Sushanta 04-08- Prananat Graduate NA
Nandi 1978 h Nandi

S. PAN No. Residential Aadhar No. / Telephone No. Experience

N Address DIN No. (Residence) in the line
o of activity
(Years)
1 AEWPB871 BLOCK A 21/10, 01161594 NIL 31 YEARS
2N MALATI NIWAS,
UTTORAYON
TWONSHIP,
MATIGARA, dist-
DARJEELING,
PIN734010
2. CHUPB476 M.H Street, 65536770896 NIL 5 YEARS
4R Asansol, 1
Burdwan, WB,
Pin-713301
3. AVMPN821 Sukanta Nagar, 08032433 NIL 20 YEARS
 6E Bagdogra, Uttar
Bagdogra, Dist.-
Darjeeling, Pin-
734014

12. Existing since 2010

ACTIVITY Proposed (#): NA
# If a different activity other than existing activity is proposed/New Unit

HOSPITAL & DIAGONOSTIC CENTRE

13.

i. Whether the MSME unit is ZED rated (Yes/No) ……………

NO……………………………
ii. If Yes,the gradation obtained by the MSME unit (Tick appropriate one)

Bronze Silver Gold Diamond Platinum

14
NA
N A PNE
a d r ax
t Names of the Associate concerns and Nature of Association
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 r/ Director or just investor
in Associate Concern
NIL

15. Relationship of Proprietor/ Partner/ Director with

NO
the officials of the Bank/ Director of the Bank (Yes/No):

16. BANKING/ CREDIT FACILITIES (EXISTING):

(Rs. in
lacs)
Type of Limit Outstanding Presentl Securitie Rate of Repayme
Facilities (in as y s Interes nt terms
lacs) on31.03.20 banking t
25 with
Current Account
Cash Credit
Term Loan 198.50 153.65 Union L&B 9% 84 months
Bank
LC/ BG
Others
Total 198.50 153.65
If Banking with our Bank, Customer No. to be given 243430455
here

It is certified that our unit has not availed any loan from any other Bank/ Financial Institution in the
past and I am not indebted to any other Bank/ Financial Institution other than those mentioned in
column No. 16 above.

17. CREDIT FACILITIES (PROPOSED):*

Type of Amou Purpose for Security
Facilities nt (in which required Primary Security Whether Collateral
lacs) (Details with Security offered (Please
approx. Value to mention yes or no) (If
be mentioned) Yes, then provide
details in column 16 &
19)
Cash
Credit**
Term Loan 373.60 For acquiring Machinery, Book Co extention of mortgage
machineries debts
LC/ BG
Others
Total 373.60
* Mandatory Fields

** Basis of Cash Credit Limit applied

Cash Projected
 credit Sal Worki Inventor Debto Credito Other Promoters
es ng y rs rs current Contributio
cycle assets n
in
month
s
N.A

18. In case of term loan requirements, the details of machinery may be given as
under:
Type of Purpose Whether Name Total cost of Contributi Loan
Machine for imported of machine (in case of on being require
/ which or suppli imported machine, made by d
Equipme require indigeno er the breakup of basic the
nt d us cost, freight, promoters
insurance and
customs duty may
be given)
FUJIFLIM MRI Indigenou Eastern 401.00 Lakhs
APERTO s Photo
LUCENT service
OPEN MRI s Pvt.
SYSTEM Ltd. 41.48 Lakhs 373.60
Lakhs
4008S NG dialysis Freseni 14.08
Hem Indigenou us
dialysis s Medical
Machine care

19. Details of Collateral Security offered, if any, including 3 rd party guarantee*

(*As per RBI guidelines banks are not to take collateral security for loans upto Rs.10 lakhs to
MSE Units)

a) Third party Guarantee:

S. Name of Father/ Resident Telephone Mobil Net Aadha PA
N Guarant Spouse ial No. e No. Wort ar No. N
o or Name Address (Residence) h (in No.
lacs)
1
2
3

b) Other collateral Security:

 S. Name of owner of Collateral Security
N Collateral Nature Details Value (Rs. In
o lacs)
1. Ranjit Bhagat Land & Building
2.
3.

20. PAST PERFORMANCE/ FUTURE ESTIMATES

(Actual performance for previous years, estimates for current year and projections for next
year to be provided for working capital facilities. However for term loan facilities projections
to be provided till the proposed year of repayment of loan):

Past Year- Past Year- Present Next Year

II (Actual) I (Actual) Year (Projection)
(Rs. in lacs) (Estimate)
Net Sales 429.61 361.42 452.00 Lakhs 565.00 Lakhs
Lakhs Lakhs
Net Profit 66.62 Lakhs 68.93 88.82 Lakhs 115.54 Lakhs
Lakhs
Capital (Net worth in case of 297.01 342.91 399.38 Lakhs 461.69 Lakhs
companies) Lakhs Lakhs

21. Status regarding Statutory Obligations:

Statutory Obligation: Remarks (Any details in Connection with the relevant obligation to be
given)
Statutory Obligation Whether Complied with (write Yes/ No). If Not
Applicable then write N.A.
1. Registration under Shops and Yes
Establishment Act

2. Registration under MSME Yes

(Provisional/ Final)

3. Drug License Yes

4. Latest Sales tax/GST return February,2025

filed
5. Latest Income tax returns Ass/ Yr : 2024-25
filed

6. Any other statutory dues No

remaining outstanding
22. a) ID Proof (Any of the following)
Passport/Voter Identity Card/Pan Card/Driving License/Job Card/Aadhaar Card/Identity
Card (subject to the satisfaction of the bank)

ID Proof No: AEWPB8712N

b) Address Proof (Any of the following)
 Electricity Bill/Telephone Bill/Bank Account statement of any other bank/Letter from
reputed employer/ Letter from recognized public authority verifying the address of the
customer to the satisfaction of the Bank/Ration Card.

Address Proof: ADDHAR NO. 788087917098

Declaration
I/ We hereby certify that all information furnished by me/ us is true, correct and complete
that I/ We have no borrowing arrangements for the unit except as indicated in the
application; that there is no overdue/ statutory dues against me/us/promoters except as
indicated in the application; that no legal action has been/ is being taken/ initiated against
me/us/promoters by any Bank/FIs. I/We shall furnish all other information that may be
required in connection with my/ our application that this may also be exchanged by you with
any agency you may deemed fit and you, your representatives or Reserve Bank of India or
any other agency as authorized by you, may, at any time, inspect/verify my/our assets,
books of accounts etc in our factory/ business premises as given above. You may take
appropriate safeguards/action for recovery of Bank’s dues including publication of defaulters
name in website/submission to RBI; further agree that my/our loan shall be governed by the
rules of your Bank which may be in force from time to time.

SPACE FOR PHOTO SPACE FOR PHOTO SPACE FOR PHOTO SPACE FOR PHOTO

Space for Signature Space for Signature Space for Signature Space for Signature

SIGNATURES OF PROPRIETOR/ PARTNER/ DIRECTOR WHOSE PHOTO IS AFFIXED

ABOVE
Only one photo of proprietor/ each partner/ each working Director is required to be
affixed. Each photo will be certified/ attested by the Branch Team with name and
signatures on the photograph with Branch stamp. The concerned staff will put his name
below the signatures.
To be signed at the designated branch only

Documents attached:

I/We have attached the copies of the following supporting documents (put a 
wherever applicable)

Proof of identity- Voter’s ID card/ Passport/ driving licence/ PAN card/ signature
identification from present bankers of proprietor, partner or Director (if a company)
 Proof of residence - Recent telephone bills, electricity bill, property tax receipt/
passport/ voter’s ID card of proprietor, partner or Director (if a company)

Proof of business address

Proof of Minority

MSME registration if applicable

Last three years’ Balance Sheets of the units along with income tax/ GST returns
etc (applicable for all cases from Rs. 2 lacs and above). However, for cases with
fund based limit upto Rs. 25 lacs if audited balance sheets are not available, then
unaudited balance sheets are also acceptable as per extant instructions of the
bank. For cases above Rs. 25 lacs, the audited balance sheets are necessary.

Projected balance sheets for the next two years in case of working capital limits
and for the period of the loan in case of term loan (for all cases of Rs. 2 lacs and
above)

Passport size photograph/s of the applicant/s

Application form

Credit information Form of concern/ promoter / guarantors, as applicable

Any other document as per checklist(Please specify)

Date:

Place: Applicant’s Signature

 CHECKLIST (For Loan upto Rs.2.00 crore)
1. Proof of Identity- Voter’s ID card/ Passport/ Driving License/ PAN card/ signature
identification from present bankers of proprietor, partner or Director (if a company)
2. Proof of residence - Recent telephone bills, electricity bill, property tax receipt/
passport/ voter’s ID card of proprietor, partner or Director (if a company)
3. Proof of business address
4. Applicant should not be defaulter in any Bank / FI.
5. Last three years balance sheets of the units along with income tax / GST returns etc.
(Applicable for all cases from Rs. 2 lacs and above). However, for cases with fund
based limit upto Rs.25 lacs, if audited balance sheets are not available, then
unaudited balance sheets are also acceptable as per extant instructions of the bank.
6. Memorandum and articles of association of the Company/ Partnership Deed of
partners etc
7. Assets and liabilities statement of promoters and guarantors along with latest income
tax returns.
8. Rent Agreement (if business premises on rent) and clearance from pollution control
board, if applicable.
9. SSI/MSME registration, if applicable.
10. Projected balance sheets for the next two years in case of working capital limits and
for the period of the loan in case of term loan (for all cases of Rs. 2 lacs and above).
11. In case of takeover of advances, sanction letters of facilities being availed from
existing bankers/ Financial Institutions along with detailed terms and conditions.
12. Photocopies of lease deeds/ title deeds of all properties being offered as primary and
collateral securities.
13. Position of accounts from the existing bankers and confirmation about the asset being
Standard with them (in case of takeover).
14. Copy of GST returns, if applicable
15. The Audited Balance Sheets are necessary for limit of Rs.25.00 lacs and above.

For cases with Exposure above Rs.25.00Lacs

16. Profile of the unit (includes name of promoters, other directors in the company, the
activity being undertaken, addresses of all offices and plants, shareholding pattern
etc.
17. Last three years balance sheets of the Associate/ Group Companies (if any)
18. Project Report (for the proposed project if term funding is required) containing details
of the machinery to be acquired, from whom to be acquired, price, names of suppliers,
financial details like capacity of machines, capacity utilization assumed, production,
sales, projected profit and loss and balance sheets for the next 7 to 8 years till the
proposed loan is to be paid, the details of labour, staff to be hired, basis of assumption
of such financial details etc.
19. Review of account containing month-wise sales (quantity and value both), production
(quantity and value), imported raw material (quantity and value), indigenous raw
material (quantity and value), value of stocks in progress, finished goods (quantity
and value), debtors, creditors, bank’s outstanding for working capital limits, term loan
limits, bills discounted.
20. Manufacturing process, if applicable, major profile of executives in the company, any
tie-ups, details about raw material used and their suppliers, details about the buyers,
details about major-competitors and the company’s strength and weaknesses as
compared to their competitors etc.
(The check list is only indicative and not exhaustive and depending upon the local
requirements at different places addition could be made as per (necessity).
Data / information at Point No.17, 18, 19 may be sought from unit requesting limit of
Rs.50.00Lacs and above.