YUVA PARIVARTAN

Kherwadi Social Welfare Association

Parishramalaya, Teen Bungalow Road, Kherwadi Bandra (East), Mumbai - 400051
(Please ensure that full and complete details are furnished against each item in the Questionnaire)

ATCC Application Form

YP Authorized Training & Certification Centre
Region :-_______

Sr.No:_______

Location :_______________________________

Date: - _____________

Dear Sir/Madam,
I the under signed, hereby apply for ATCC status of my training center. I want to get an authorization of
Yuva Parivartan (KSWA) as an Examination & Certification center under your ATCC model. I have read all the
terms & conditions. I agree to abide by the all rules and regulations of KSWA (YP).
The Name of the Institute (In Capital):
Address of the Institute (In Capital): _________________________________________________________
Place:

________________Taluka: ____________________ Dist.: _

__________________________

Pin code:
Tel. No. (With STD Code):

E-Mail ID:

_____________________________________

Fax No. :
Nearest Railway Station:

Local Bus Stop:

(Please indicate the nearest big city and approximate distance)

Land Mark:
Institute Time:

To

1. Name of Proprietor / Director :

Residential Address: ____
Res. Tel. No.
Qualification:

Weekly Off:

2. Name of Managing
a. President
b. CEO
c. Secretary
d. Treasurer

Committee Members:
: __________________
: __________________
: __________________
: __________________

3. Number of personnel working

a. Full Time : __________________
b. Part Time : __________________
c. Volunteers : __________________
(Attach separate sheet with details of personnel containing name, qualification, course teach, contact
number, experience)
5. Registration Number & Date under
a. Society Registration Act: _____________________________________
b. Public Trust Act:

_____________________________________

c. Details of Shop & Establishment Licenses( Gumasta license-No: and Validity):____________________

6.

Number of years of working in Welfare /Training activities:

7. Income-Tax Exemption No. u/s. 80G any other (please specify) (If applicable and Available)
_________________________________________________________
8.

Annual Budget d. Welfare/Training Activities : _____________________________________________________

e. Staff Salary

: _____________________________________________________

f. Other Administrative Cost : _____________________________________________________

g. Any other Total

: _____________________________________________________

2. Sources of Fund (amount in last two years only, if applicable and Available).
Sr
No
1
2
3
4

Particulars
Government/Semi-Govt.
Grants(Central/State/Municipal)
Donations : Individuals
Foreign Funds

2011-12

2010-2011

5
6
7
8
9

Local Contributions
Membership Fees
Income from Training
Service Charges
Any donation in kind

3. Courses Details
a. ____________________________________________ Duration (in hrs) __________
b. ____________________________________________ Duration (in hrs) __________
c. ____________________________________________ Duration (in hrs) __________
d. ____________________________________________ Duration (in hrs) __________
e. ____________________________________________ Duration (in hrs) __________
f.

____________________________________________ Duration (in hrs) __________

g. ____________________________________________ Duration (in hrs) __________

(Attach separate sheet with course wise list of equipments with quantity)
4. Details of Accommodation:
a. No of classroom _________________________________ Size (sq. ft.) __________
I confirm the entire information required by you is furnished in this questionnaire and it is true.
Name of Signing Authority: ________________________________________
Date: ____________
Seal/Stamp of the organization: ____________________________________________________
Enclosures required
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

Registration Certificates
Layout map of your institute
Acknowledgment of Income Tax Return.
Latest Annual Report
Letter of Consent/ LOI from the Organization/ Head
Details of personnel containing name, qualification, course teach, contact number, experience
Course wise list of equipments with quantity
Any other important documents(income tax exemption etc)
Shop & Establishment License
The agreement/ Leave and license /Lease/Rent/Property Photostat (Xerox) copies