PART 1: APPLICANT DETAILS
Name of the Applicant
Member Code
Folio No.
Date of Birth
Complete Address.
Mobile No.
Email ID
PART 2: MILK POURING PATTERN
Pouring pattern of the member in two previous years
Previous Year 1
1 April 2024 to 31 March 2025
Days of milk poured in 365 days.
Quantity of Milk Supplied.
Number of Equity Shares as on 31.03.2025
Previous Year 2
1 April 2025 to 31 March 2026
Days of milk poured in 365 days.
Quantity of Milk Supplied.
Number of Equity Shares as on 31.03.2026
PART 3: SELF DECLARATION
I hereby declare that I wish to be considered for appointment as an Additional Director on the Board of Saamarthya Milk Producer Company Limited.
I further confirm that I am not disqualified from becoming a Director under Section 164 of the Companies Act, 2013, the applicable rules made thereunder, and the Articles of Association of the Company.
The following declarations are made by me voluntarily and shall form part of my nomination application.
The specific declarations in this regard are as follows:
Particulars of Disqualification & Declaration (Yes/No)
PART A
Criminal Conviction: I have been convicted by a Court of any offence involving moral turpitude and sentenced to imprisonment for not less than six (6) months.
Default in Repayment (External): I have made a default in repayment of any advances or loans taken from any company, institution, or any other person, and such default continues for ninety (90) days.
Default in Repayment (Internal): I have made a default in repayment of any advances or loans taken from the Company (Saamarthya).
I am currently a vendor (other than milk pouring vendor) or Sahayak of the Company.
The Producer Company, in which I am director: a. has not filed the annual accounts and annual return for any continuous three financial years commencing on or after the 1st day of April, 2002; or b. has failed to, repay its deposit or withheld price or patronage bonus or interest thereon on due date, or pay dividend and such failure continues for one year or more;
Failure to Hold Elections: Default is made in holding elections for the office of Director in the Producer Company, in which I am a Director, in accordance with the provisions of the Act and the Articles of Association.
Damage to Company's Interest: I have committed any act which has damaged the interest and reputation of the Company.
Wilful Deception: I have wilfully deceived the Company or its Board of Directors.
Non-Compliance in Calling Meetings: I have caused the Annual General Meeting or Extraordinary General Meeting of the Company to not be called in accordance with the provisions of the Act (excluding natural calamities or similar reasons) in which I am serving currently as Director.
Educational Qualification: I have not passed at least 10th or equivalent standard from any recognized educational institution.
Political Affiliation: I am a member of any legislative body (Parliament, State Legislature, Zilla Parishad, Gram Panchayat) or an office bearer of any political party at village, Taluka, District, State, or National level.
Mental Capacity: I am of unsound mind and stand so declared by a competent court.
Insolvency: I am an un-discharged insolvent, or have applied to be adjudicated as insolvent, and such application is pending.
Training Programme: I have failed to complete the prescribed training programme (within six months of selection), despite being given the opportunity. (Note: As this is a fresh application, this condition will apply post-appointment; however, I confirm my willingness to complete it.)
Not Applicable (Willing to comply)
No
Yes
DIN Allotment: I have not been allotted a Director Identification Number (DIN).
I or my relative has or had any pecuniary relationship or transaction directly or indirectly with company (except membership benefit) amounting to two percent or more of its gross turnover or total income or twenty-five thousand rupees or such higher amount as may be decided by the Board, whichever is lower, during the two immediately preceding financial years or during the current financial year.
PART B
PART 4: NOMINATION CLASS
PART 5: DOCUMENT UPLOADS
Upload self-attested copy of below documents
PAN Card
Aadhaar Card
High School / Higher Qualification Certificate
Passport Size Photograph
Place
Submit Nomination