APPLICATION FORM

FOR SEEKING FINANCIAL ASSISTANCE UNDER COMMUNITY RADIO SUPPORT SCHEME

[Please read the policy guidelines carefully before filling the application form]

The Secretary, Ministry of Information & Broadcasting ‘A’ Wing, Shastri Bhawan, New Delhi – 110 001

Madam/Sir, I hereby submit the following details in support of the eligibility, as prescribed in the guidelines for Community Radio Support Scheme 1. APPLICANT’S DETAILS:

i) Name of the Community Radio…………………………………………............................................

ii) Name of the organisation………………………………………………..……………. …....................

iii) Service Tax No.........................................PAN No..............................TAN No...............................

iv) Address of Correspondence …….……………………………………………………………….........

.…………………………………………………………………...............................................................

District………………………….State…….……………..……….PIN……………………......................

v) Name of Authorised Signatory (Mr./Ms) ...............….....................................................................

Designation..........................................................Contact No. …….……………..…….....................

E-Mail ID………………...................................................................................................................... 2. Community Radio On-Air Launch Date (Only for Operating CRS)…………….…………......................

3. Expected date of Launch of CRS (Only for LOI Holders) ………………… ...........................................

4. Is your organisation registered on Central Planning Scheme Monitoring System’s website www.cpsms.nic.in ? [It is mandatory for Financial Assistance.]

a) If Yes, Provide Unique Code ……………………………………………………………………..............

b) If No, .............................................[Please provide requisite information in Annexure-4]

5. Please provide details of bank account where grant may be transferred. Also enclose a cancelled cheque of same bank account.

Name of the Account Holder…………………………….........................................................................

Account Number…………….......................................IFSC/RTGS Code ...............................................

Name & Address of Bank...... ………………..........................................................................................

Signature of the authorised Signatory Date: Place: OFFICE SEAL

Annexure-3

DECLARATION

(To be submitted on organisation’s letter head)

1. I/we hereby confirm that I have gone through the Guidelines for Community Radio Support

Scheme (CRSS) and have noted the provisions and term and conditions for receiving financial

assistance/grants.

2. I/we also declare that the information given in this application and any supplementary

documentation is, to the best of my knowledge and belief, true and Correct.

Signature of the authorised Signatory Date: Place: OFFICE SEAL

Annexure-4

DETAILS OF GRANTS RECEIVED BY THE ORGANISATION IN PAST THREE YEARS

Part-A

Sl.

No.

Month & Year

of grant

received

Amount of Grant received

(in Rs.)

Granting Organisation

Purpose of Grant received

(Please furnish three years Audited Balance Sheet/Statement of Account of the Organisation.)

Part-B

Have you received any grant for CRS equipment so far/till date? If yes, provide details.

…………………………………………………………………………………………………………..

…………………………………………………………………………………………………………..

…………………………………………………………………………………………………………..

…………………………………………………………………………………………………………..

…………………………………………………………………………………………………………..

…………………………………………………………………………………………………………..

…………………………………………………………………………………………………………..

Signature of the authorised Signatory Date: Place: OFFICE SEAL

Annexure-5

INFORMATION TO BE PROVIDED FOR

CPSMS REGISTRATION

i) Type of registration ………………………………………………………………….. ...............

(Select any type among mentioned in brackets below)

[ Whether Central Govt, Central Govt PSU, State Govt PSU, Statutory Body, Local Body, Registered Society (NGO),

Private Sector Company, Trust, Individual, Institutional Organisation, State Govt Institution]

ii) Name of Organisation .........………………………………………………………………............

iii) Act/Registration No.: .……………………………………………………………………... ...........

iv) Date of Registration (DD/MM/YYYY) : ………………………………………………….. ...........

v) Registration Authority: ..…………………………………………………………………... ...........

vi) State of Registration: ..…………………………………………………………………… ...........

vii) TIN Number (If applicable) : ……………………………………………………………… ...........

viii) TAN Number (If applicable) : ………………………………………………………….................

ix) Correspondence Address …….………………………………………………………………......

………………………………………………………………........................................................

District………………………….State…….……………..……….PIN……………………............

Signature of the authorised Signatory Date: Place: OFFICE SEAL

Annexure-6

FORMAT TO PREPARE DETAILED PROJECT REPORT (DPR)

1. Please give a brief general overview of your station summarizing its target

community, the objectives of the CR station (Not more than 500 words in total)

2. Please explain what the grant is for (Equipment acquisition/up gradation). Please attach

estimates obtained from vendors; you may supply this information on a separate sheet of

paper.

3. Give your reasons why you need this grant and why it is important to the running of your

station (in no more than one page).

4. Please also explain about your plan to make the CR Station self-sustainable.

INSTRUCTIONS & CHECKLIST OF MANDATORY/SUPPORTING

DOCUMENTS WITH APPLICATION FORM

Instructions:

1. Please read the policy guidelines carefully before filling the application form. 2. Check that all the sections of Application Form are correctly filled and supporting documents have been

attached. 3. Supporting documents should be tagged properly with application form and must be in same order as

given in the Checklist. 4. Furnish necessary information in Annexure 1-5 of application form. 5. Each and every page attached with application form should be signed & stamped by authorised

signatory 6. It is compulsory that Compliance Statement(Available at Annexure-2) must be completed signed and

stamped by respective vendor for the equipment listed for Financial Assistance.

Checklist for New Station (LOI holders in the process of setting up stations) 1. Documents which have been issued to the applicant:

a) Copy of Letter of Intent (LoI) issued by MoIB b) Copy of Grant of Permission Agreement (GoPA) signed with MoIB

c) Copy of Frequency allocation letter from DoT or Copy of correspondence with WPC or any correspondence from WPC in this regard.

d) Copy of SACFA clearance letter from WPC or Copy of correspondence with WPC or any correspondence from WPC in this regard.

2. Quotation in original duly signed and stamped by the vender. 3. Compliance Statement (As per Annexure-2) 4. Annual report of organization for last 3 years 5 Complete audited balance sheets of organisation for last 3 years. 6. Detailed Project Report (as per Annexure-6 of application form) 7. Document in support of source of 50% amount to be contributed by the applicant (as mentioned in clause (10) of the guidelines). 8. One cancelled cheque of your bank account.

Checklist for Operational Station (On-Air Stations)

1. Documents which have been issued to the applicant:

a) Copy of Letter of Intent (LoI) issued by MoIB b) Copy of Grant of Permission Agreement (GoPA) signed with MoIB

c) Copy of Frequency allocation letter from DoT d) Copy of SACFA clearance from WPC e) Copy of wireless operating license (WOL)

2. Quotation in original duly signed and stamped by the vender. 3. Compliance Statement (As per Annexure-2) 4. Annual report of organization for last 3 years 5. Complete audited balance sheets of organisation for last 3 years. 6. Detailed Project Report (as per Annexure-6 of application form) 7. Document in support of source of 50% amount to be contributed by the applicant (as

mentioned in clause (10) of the guidelines) 8. One cancelled cheque of your bank account. 9. Affidavit to the effect that station has been on air for at least three months. 10. Photograph of studio and station premises. 11. Content CD containing on-air content for last three months of broadcast