1. DRISHTI FARM TO FORK CLUB (DFTFC)
Page 1 of 6
Registration Form
FRN Number : ______ ______ __________
Name of Member :______ _______ __________
Contact Person :______ ________ __________
Present Address : ________ _________ ________
Farm Address :________ __________ ________
Mobile No : _____________ Email :_________ _____________
Caste : GENETAL/ RESERVED Category : Small / Marginal / Corporate/ Landless Farmer
Socio-Economic Status of Member : _______ ________ _________
KYC DETAILS
Sr.No. Particulars ID Card Number Issue Date Expiry Date Issuing Authority
1 PAN Card
2 Election Card
3 Driving License
4 Aadhar Card
5 Pension Card
6 Passport
FAMILY DETAILS
Sr.
No.
Name &
Relationship
PAN
No.
Date of
Birth
Education Experience
Land
Holding
In Acres
Income &
Its Source
Contact
No.
Details of Technologies Adopted for Farming :
Micro-Irrigation :
Protected Cultivation :
Farm Mechanisation :
Details of Subsidies / Government Schemes Benefits availed till date :
Request for Services of SCSG :
1. Techno-commercial Advisory of Agri – Projects
2. Technical advisory for Crop Production & Pest Management
3. Technical Advisory on Post Harvest Management
4. Marketing Support for Agri Produce
5. Support in availing Agri Inputs for Farming and Medicines for Animal Husbandry
6. Support & Advisory on Availing agri-finance from banks
7. Advisory on Financial Management for better Farm Operations
8. Advisory on Government Schemes for Agriculture and Rural India
Affix Latest
Photographs
2. DRISHTI FARM TO FORK CLUB (DFTFC)
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FARM DETAILS
Sr.
No.
Survey/
Block
No.
Moje &
Taluka
Type of
Holding
Area
Hectare
Type of Land
Type of
Irrigation
Charge on land, if any
Free hold
Lease Hold
Jt
Ownership
Irrigated
Pasture
Plantation
Cultivable
Surface
Tubewell /
Canal /
Dug Well /
Drip /
Sprinkler
(submit copies of documents of land holdings)
Animal Husbandry Details: Cow : _____ , Buffalo : ______ , Other____: ________
Average Milk Per day :________ Litres, Price/ Lt ____ Rs. = Income PA :__________ Rs. ( 270 days of 80% Cattle)
Cost of Production Of Milk : Labour Per day : ____ Man Hours, Medicines & Nutrition :______ Rs. / Month, Feed /
day ____ Kgs @ Rs.___/ Kg
Present Income Details :
Income from Farm Operations : ______________________________________
Income from Animal Husbandry : ______________________________________
Income from Other Sources (_______) : ______________________________________
BANK DETAILS
Sr.
No.
Name of the Bank Branch Name
Type Of Account
& IFSC Code
Account No.
Average Balance &
Banking Conduct
CROP DETAILS
Crop
Date of
Sowing
Cost of Production.
Total
Cost
of
Cultiv
ation
Total Yield
Gross
Income
Other Costs
Like -
Insurance ,
Finance,
Comission
etc…
Remark
Labour
& Land
Preparat
ion
Planting
Materials,
Nutrition &
Pest Mgt
Harvesti
ng, Post
Harvesti
ng &
Mktg
(submit copies of documents for Income & Expenses )
3. DRISHTI FARM TO FORK CLUB (DFTFC)
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ASSET DETAILS
A. IMMOVABLE ASSETS
Sr. No.
Nature of
property
Location
Freehold /
Leased /
Jointly owned
Cost (at the
time of
purchase)
Present
estimated
market value
of the
property/ies
Whether encumbered
/unencumbered/ partially
encumbered. Give details.
(with whom, consideration
and major T&C)
1
House /
Building
2
Tractor Shed /
Farm Shed
3 Fish Pond/Tank
4
5
6
B. MOVABLE ASSETS
Sr. No. Nature of property Number Cost of Purchase Present Market Value
1 Ploughing animal
2 Milch animals
3 Farm birds
4 Diesel Motor Pump
5 Electric Motor Pump
6 Transport Vehicle
7 Tractor
8 Other implements
9
10
C. LIC POLICIES
Sr. No. Particulars Policy-1 Policy-2 Policy-3 Policy-4 Policy-5
1 Policy No.
2 Date of issuance of policy
3 Sum Assured (Rs.)
4 Branch Name
5 Annual Premium (In Rs)
6 Premium paid to what period
7 Name of the Co.
8 Total No. of Shares held
9 Certi. No. A/C No.
10 Total Amt Rs. (Face value)
11 Whether fully paid? (YES/NO)
12 Current Market Value Rs.
D. TERM DEPOSITS
Sr. No. Particulars 1 2 3 4 5
1 FDR/RDYSJY A/C No.
2 Date
3 FVG.
4 Amt. Rs.
5 Name of Bank/ Branch
6 Due Date
7 Maturity Value Rs.
E. INVESTMENT IN GOVT SECURITY LIKE BONDS/NSE etc.
Sr. No. Particulars 1 2 3 4 5
1 Bond/ Certi. No.
2 Date of Purchase
3
Issuing Office/ Post office Add.
(including mutual Fund)
4 Amt. Rs.
5 Due Date
6 Maturity Value Rs.
4. DRISHTI FARM TO FORK CLUB (DFTFC)
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LOAN/LIABILITY DETAILS
A. Details of Borrowing
Sr.
No.
Name of
lending
institution/
Bank
Purpose
of Loan
Present Out
Standing
Amount of
instalment
due during
the year
Overdue Amt of
Installment (If
Any)
Collateral Security
Offered
B. Liabilities as a Guarantor
Sr.
No.
Guarantee
given on
behalf of
Name of Bank/Institution in whose favour
guarantee is given
Amount of
guarantee
Present
outstanding/
liability
Status of
A/c
(Regular/
Overdue)
Type of Loan Requested : ____________________ _______________________________________
Amount of Loan Requested : Rs.___________________________
Purpose of Loan : _________________________________________
Expected Repayment Schedule : _____________________________
DETAILS OF SECURITY TO BE OFFERED
Sr.
No.
Details of Property
Estimated Market
Title StatusMarket
Value
Realisable
Value
Distress
Value
A. Primary
i
ii
iii
B. Collateral (wherever applicable)
i
ii
iii
DETAILS OF GUARANTORS (IF ANY)
Sr. No. Name of The Guarantor Address Net worth
DECLARATION
I / we hereby declare that the information given above is true and correct to the best of my/our knowledge
and belief. I/we hereby authorize the Shiva CSG Pvt Ltd to disclose all/any of the details/information available
with the Company relating to my membership accounts in case of need or as desired by the company to
any other financial institution, government or any other agency/agencies. If any information given by me/us
is found to be incorrect, the Company will have the right to disqualify me/us for availing any membership
benefit & Credit facility.
I/we hereby declare that as on the date of the application, there is no other loan/liability outstanding in
my/our name other than those mentioned above.
I/we hereby undertake that on sanction of the loan we shall abide by the terms and conditions laid down by
the Financial Institution and will inform the respective agencies about the acquisition of other assets during
currency of the loan.
Place:
(Signature/Thumb Impression of
Borrower/s)Date:
5. DRISHTI FARM TO FORK CLUB (DFTFC)
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Salient Features of DFTF Club Membership :
1. Timely advisory on Crop Production, Crop Protection and Crop Nutrients by Experts of Shiva
Consultancy Group
2. Regular & Continuous Field visit for Farm Operations of Agriculture, Horticulture, Farming, Dairy and
Integrated Farm Operations by Shubham Agribusiness Services.
3. Regular Advisory on Banking, Finance, Investment and Government Schemes related to Farming and
Rural Development by professional team of Shiva CSG Pvt Ltd..
4. Education and Training for Employment Generation activities within the rural area by Shiva CSG Pvt Ltd.
5. Uninterrupted Supply of Relevant Farm Inputs directly to farm for smooth operations through dedicated
Agripreneurs chain of Drishti Biotech Pvt Ltd in your area & through Portal D2F on Discounted Rates.
6. Support and advisory on Value addition in Farm Produce and Marketing through dedicated network of
D2F Portal and Shiva Consultancy Group
Terms & Conditions Of DFTF Club Membership :
1. Any Farmer with minimum 5 Acres of Land can become member of DFTF Club by paying ( following 3
types of fees)
a. Form Fee @ Rs. 100 per acres of Land Holding ( One time Form Fee) ,
b. Membership & Service Fee @ Rs. 1000 per Acres/ Annum &
c. Refundable Security Deposit @ Rs. 2000 per Acres .
2. Any member of DFTF Club is entitled to avail
a. Credit facility of Rs. 5000 per acres for Agri Input Supply by Drishti Biotech Pvt Ltd and
b. Free Advisory on Farm Management and Commodity Marketing by Professional Team of Shiva
CSG Pvt Ltd.
3. Any member can avail assistance of Financial Advisory Services for the year by giving request along
with only 10% of Fees decided mutually and rest after completion of the project.
4. Duly filled in DFTFC form along with following documents need to submit to Shiva Consultancy Group to
allot Membership Number and detailed scope of services
a. Copy of all relevant KYC documents,
b. Copy of Land related documents and
c. Copy of banking related documents.
Declaration :
I/ we _______________________________________________________ understand all the terms and conditions of the
membership and thus paying the form Fees of Rs.____________ towards my total land of _____ Acres as per
details filled in application form. Further paying Rs. _______________ by Cash/ Cheque/ DD No_____________
Dated ___________ from________________________________ towards Annual Membership & Service Fee and
Security Deposit in favour of Drishti Biotech Pvt Ltd.
I / we declare that all the information provided in the form are true. I/we will abide all the instructions provided
by Shiva Consultancy Group for betterment of my Farm Productivity, profitability and Socio-cultural betterment.
I / we promise to pay timely / on demand all the bills and Invoices raised by Shiva Consultancy Group and any
Business associates in Good faith towards Products and Services supplied by them to keep smooth business and
transparent operations.
Place:
(Signature/Thumb Impression of
Borrower/s)Date:
For Office Use Only : Allow / Disallow
Assign Membership Number :
