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All parts of the application must be completed and sent with the entry fee (Non Refundable) relevant to your category.whÿïmf;a ish¨u fldgia mqrjd iïmQ¾K l<hq;= w;r Tnf.a ldKavhg wod< we;=<;a ùfï .dia;= ^wdmiq fkdf.jk& iu`. wm fj; túh hq;=h.

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7

WOMAN ENTERPRENEUR OF THE YEAR – 2013jif¾ ldka;d jHjidhsldj 2013

2013 Mk; Mz;bd; ngz; njhopy; Kidtu; njhopw;Wiu cupikahsu;

APPLICATION FORM / whÿï m;%h $ tpz;zg;gg; gbtk;

BUSINESS CLASSIFICATION: jHdmdßl j¾.SlrKh tu;j;jfg; gupT

MICRO SMALL b;d l=vd iq¿ Ez;zpa rpwpa

(Please tick the appropriate box/lreKdlr wod< fldgqfõ ,l=Kq lrkak$Njitahd ngl;bapy; rupaplTk;)

PART 1: PERSONAL INFORMATION (*It is compulsory to fill this section.) 1 fldgi ( fm!oa.,sl f;dr;=re ^fuu fldgi iïmQ¾K lsÍu wksjd¾H fõ’ & gFjp 1: jdpg;gl;l tpguq;fs; (,e;jg; gFjp fl;lhak; epug;gg;gl Ntz;Lk;) (Attach 2 passport size colour photographs of the applicant)

^.uka n,m;% m%udKfha j¾K cdhdrEm folla fï iu. wuqKkak' &

(2 flTr;rPl;L msT tu;zg; Gifg;gl gpujpfis tpz;zg;gj;Jld; ,izf;fTk;)

1. Name in Full :……………………………………………………………………………………………………………………………………… iïmQ¾K ku KOg; ngau;

2. Date of Birth :.............................................. Age :...................................... Wmka oskh gpwe;j jpfjp jhi taJ

3. NIC No. :....................................................... cd;sl ye÷kqïm;a wxlh Nj.m.m. ,y

4. Civil Status Married Single újdyl $ wújdyl nj újdyl wújdyl tpthf epiy / Fb Kiw tpthfkhdtu; jdpahdtu;

If married újdyl kï / tpthfkhdtuh; Mapd;

Husband’s Name :………………………………………………………………………………………………………………….…………… iajdñmqreIhdf.a ku / fztupd; ngau;

Job :……………………………………………………………………………………………………………………………….......…………….. /lshdj / njhopy; No. of Dependents :…………………………………. hefmkakka ixLHdj / rhu;e;Js;stu;fspd; vz;zpf;if

5. Postal Address :…………………………………………………………………………………………………………………………………… ,smskh ……………………………………………………………..……………….......……………………………………………… jghy; Kftup ……………………………………………………………..……………….......………………………………………………

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6. Telephone: Office :………………………………………... Fax :………………………………………... ÿrl:k wxlh ld¾hd,h *elaia njhiyNgrp mYtyfk; njhiyefy;

Home :………………………………………... Mobile :...................................... ksji cx.u tPL ifalf;fnjhiyNgrp

7. E-mail :…………………….....................………................................................................................................... úoaHqq;a ;eme,a ,smskh ,nkapy;

8. Educational Qualifications:…………………………………………………………………………….....................………………… wOHdmk iqÿiqlï …………………………………………………………………………….....................………….……… fy;tpj; jifikfs; ………….……………………………………………………………….......................………….……… ……………………………………………………………………………………………………………………………….......…………….......... ……………………………………………………………………………………………………………………………….......…………….......... ……………………………………………………………………………………………………………………………….......……………..........

9. You may attach a brief description of yourself/family. Tn $ Tnf.a mjq, ms<sn| flá úia;rhla wuqkkak' tpz;zg;gj;jhup FLk;g tpgur; rpW Fwpg;ig ,izf;fTk;

10. How do you describe your line of business? Tnf.a jHdmdrh ms<sn| úia;rhla imhkak' cq;fspd; tpahghuj;jpd; jd;ikia ePq;fs; vt;thW tpgupg;gPu;fs;

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

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Part II – BUSINESS INFORMATION 2 fldgi - jHdmdr f;dr;=re gFjp II - tpahghu tpguk;

1 Name of the Organization wdh;kfha ku epWtdj;jpd; ngau;

2 Contact PersoniïnkaO l, yels mqoa.,hd njhlu;ghsupd; ngau;

3 Names of Directors/Partners wOHlaIjrekaf.a $yjq,alrejkaf.a kï,af;Feu;fs; gq;fhsu;fspd; ngau;fs;

4 Registered Address ,shdmÈxÑ ,smskh gjpT Kftup

5 Contact Details iïnkaëlrk f;dr;=re njhlu;ghd tpguq;fs;

5.1 Telephone $ ÿrl:kh $ njhiyNgrp

5.2 Fax $ *elaia $ njhiyefy;

5.3 E-mail $ úoaHq;a ;eme,a ,smskh $ kpd;dQ;ry;

5.4 Web $ fjí ,smskh $ ,izak;

6 Business Registration No & Date jHdmdrfha ,shdmoxÑ wxlh yd Èkh tpahghu gjpT ,y. jpfjp

PV _______ of ________(D/M/Y)

7 Legal Status of the Business Entity jHdmdrfha kS;suh iajNdjh rl;lg;gb tpahghuj;jpd; epiy

( ) Proprietorship ( ) Partnership ;ks mqoa., jHdmdr yjq,a jHdmdr jdp gq;Flik

( ) Private Limited Company iSudiys; mqoa.,sl iud.u tiuaWf;fg;gl;l jdpahu; epWtdk;

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8 Nature of Business jHdmdrfha iajNdjh tpahghu eltbf;if tpguq;fs;

( ) Manufacture - Finished Products / ksIamdok - ksuejqï NdKav / cw;gj;jp KbTg; nghUl;fs; ( ) Manufacture - Raw materials / ksIamdok - wuq øjH / cw;gj;jp %yg;nghUl;fs; ( ) Tourism / ixpdrl jHdmdrh / Rw;Wyhj;Jiw ( ) Agro Products / lDIs ksIamdok / tptrhag; nghUl;fs;( ) Trading / fj<|dï / tpahghuk;

Service Category ( tick relevant Category ) fiajd jHdmdrNritg; gpupT

( ) Hospitality / wd.ka;=l i;aldrl fiajd / cgrhuk; ( ) Educational / wOHdmksl / fy;tp ( ) Entertainment / úfkdaod;aul / Nfspf;if ( ) Beauty / rEm,djKHh / mofpay;

( ) Others Please specify :........................................................................................................... fjk;a - ^ úia;r lrkak'& ............................................................................................................NtW jaTnra;J Fwpg;gplTk; ...........................................................................................................

8.1 Business Classification (please tick) (igyka lrkak) (Fwpf;fTk;) jHdmdr j¾.SlrKh tpahghug; gpupT

( ) Import / wdkhk / ,wf;Fkjp ( ) Export / wmkhk / Vw;Wkjp ( ) Local distribution / foaYsh fnod yeÍï / cs;ehl;L tu;j;jfk;

8.2 Brief profile of the Business jHdmdrfha iajNdjh ms<sn|j flá úia;rhla lrkak' tpahghujij gw;wpa rpW tpguk; ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................

8.3 Details of Holding Company / Subsidiaries/ Associate Companies/Agencies/Branches (if applicable) nyq úO iud.u $ wkqhqla; wdh;kh$ wdY%s; fj<| iud.u$ ksfhdacs; wdh;kh$ YdLd ms<sn| úia;r ^wod, kï muKla& tpahghu FOkk; / cgfk;gdp/ ,iz fk;gdpfs; / Kftu; / fpis gw;wpa tpguk; (VjhtJ ,Ug;gpd;) ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. .............................................................................................................................................................

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9 TIN NumberTIN wxlh' TIN ,y.

10 EPF/ ETF Registration No.(if applicable) fia(w(w($fia(ks(Nd(w( ,shdmÈxÑ wxl ^wod, kñ muKla'& C.Nr.ep/ C.e.ep gjpT ,y. (VjhtJ ,Ug;gpd;)

11 Number of Employees fiajl ixLHdj gzpahsu;fspd; vz;zpf;if

Temporary;djld,sl jw;fhypf

Permanent iaÓrepue;ju

Casualwkshï

rkahrka

Managerial l<uKdldr epu;thfk;

Supervisorymßmd,kNkw;ghu;it

SkilledmqyqKqgapw;rpngw;w

Semi Skilledw¾O mqyqKq gFjp gapw;rp ngw;w

UnskilledkqmqyqKqgapw;rpaw;w

Totaltl;=jnkhj;jk;

12 Details of Experience and Training obtained from Local/International /consultancy institutions. foaYssh$ cd;Hka;r$ WmfoaYl wdh;k fj;ska ,nd.;a mqyqKqj ms<sn| úia;r cs;Su; / ru;tNjr / MNyhrid epWtdq;fs; Kftu; MfpNahuplkpUe;J ngw;w mDgtq;fs; / gapw;rpfs; gw;wpa tpguk; ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................ ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. .............................................................................................................................................................

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13 Give brief description of new products, innovation introduced by your organization Tnf.a wdh;kh úiska ksmojQ kj ksIamdokhla y÷kajd ÿka kfjd;amdok ms<sn| flá úia;rhla i|yka lrkak' cq;fs; epWtdjjpd; Gjpa jahupg;Gfs; fz;Lg;gpbg;Gfs; gw;wpa rpW tpguk; juTk; ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. .............................................................................................................................................................

14 Details of awards received by your organization Tnf.a wdh;kh úiska ,nd .;a we.hSï yd iïudk .ek úia;r cq;fs; epWtdj;jhy; ngwg;gl;l tpUJfs; gw;wpa tpguk

Name of the award iïudkfha ku tpUjpd;ngau;

Presented bym%Odkh l, wdh;kh

toq;Fdu;

YearjirtUlk;

15 Membership in other Associations fjk;a ix.uhkays idudÔl;ajh NtW mikg;GfSldhd mq;fj;Jt tpugk;

Associationix.uhrq;fk;

Year of ElectionidudÔl;ajh ,enQ

j¾IhNju;T nra;ag;gl;l

Mz;L

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Part III – Financial Information3 fldgi - uQ,H f;dr;=re gFjp III - epjp jfty;fs;

Investment in Fixed Assets Rs in ‘000’ ia:djr j;alïys wdfhdackh re ( —000˜ epiyahd nrhj;Jf;fspd; Nkyhd KjyPL & '000"

Land bvï fhzp

Buildings f.dvke.s,sfl;blk; Plant & Machinery hkaf;%damlrK iy iúlsÍï,ae;jpu cguzq;fs;

Other Fixed Assets fjk;a ia:djr j;alï NtW epiyahd nrhj;Jf;fs;

Total tl;=j nkhj;jk;

Types of Machinery hkaf;%damlrK j¾. ,ae;jpuq;fspd; tif

Quantity m%udKh vz;zpf;if

Value jákdlungWkjp

01 Details of Assets j;alï úia;r / nrhj;J tpguq;fs; ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................ ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. ............................................................................................................................................................. .............................................................................................................................................................

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02 Detailed financial information of your business entity for past three years. miq.sh ;=ka jirl Tnf.a jHdmdr wdh;kh ms<sn| .sKqï úia;r' fle;j %d;W tUlq;fspy; cq;fs; tpahghuj;jpd; epjpepiy tpguk;

Financial Year / uqo,a j¾Ihepjp Mz;L

2010 / 2011 2011 / 2012 2012/2013

Capital / m%d.aOkh%yjdk;

Turnover (Sales Taxes) / msßjegqu ^fj<| noao&tpw;gid (tpw;gid tup)

Cost of Sales / úl=Kqï msßjehtpw;gid nryT

Gross Profit / o< ,dNh nkhj;j ,yhgk;

Net Profit / Y=oaO ,dNh epfu ,yhgk;

03 Details of your Bankers Tnf.a nexl= lrejkaf.a úia;r cq;fs; tq;fpahsu; gw;wpa tpguk;

1. Name of the Bank nexl=fõ ku tq;fpapd; ngau;

BranchYdLdjfpis

Account type (Current / Saving).sKqï j¾. ^cx.u$b;sß lsÍï&

fzf;F tif (eilKiw/Nrkpg;G)

2. Loans Kh fld;

Typej¾.tif

ValuejákdlungWkjp

3. Other credit facilities obtained from Financial Institutions. fjk;a uQ,H wdh;k fj;skaa ,nd.;a Kh myiqlï NtW epjp epWtdq;fsplkpUe;J ngwg;gl;l fld; rfjpfs; epWtdq;fsplkpUe;J ngwg;gl;l fld; rfjpfs;

Type of facility myiqlï j¾. fld; trjpapd; tif

Amountuqo,a m%udKhnjhif

Period ld,h

fhy msT

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Part IV – CORPORATE SOCIAL RESPONSIBILITY 4 fldgi - iduQysl iudÔh j.lSu gFjp - 4 $l;L r%f nghWg;G

01 What are the social benefits accruing to the society in general and neighborhood in particular? Tnf.a jgmsgdjg iy fmdÿfõ iudchg ,efnk m%;s,dNh ljfrla o@ nghJthf r%fj;Jf;Fk; Rw;wj;Jf;Fk; tpNrlkhf fpilf;fg;ngWk; gad;fs; vit?

02 Describe the social responsibility activities carried out by your organization which benefits your community and society. iudchg yd ck;djg m%;s,dN ,efnk mßÈ wdh;kh úiska bgq lrk ,o iudc j.lSï .ek úia;rhla lrkak' r%jhaj;Jf;Fk; cq;fs; r%fj;Jf;Fk; cq;fs; epWtdj;jpd; r%f epWtdj;jpd; r%f nghWg;G eltbf;iffshy; fpilf;fg; ngWk; ed;ikfis tpgupf;fTk;. Mapd;> tpguq;fs;

03 Is your product certified by Accredited Certified Agencies with regard to Quality Assurance? If yes. Provide Details ISO 9000, ISO 14000, ISO 22000, HACCP, BRC, JAS, Organic Certification etc. n,h,;a iy;sl lsßfï wdh;k u.ska Tnf.a ksIamdok j, ;;ajh iy;sl lr we;ao @ tfia kï úia;r bÈßm;a lrkak' Wod(ISO 9000, ISO 14000, ISO 22000, HACCP, BRC, JAS, Organic iy;slh' cq;fs; cw;gj;jp nghUs; ju epu;zaj;ij rhd;WgLj;Jk; VjhtJ Kftu; epWtj;jhy; juepu;zag; gLj;jg;gl;Ls;sjh?

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Part V –VISION 5 fldgi - o¾Ykh gFjp 5 - juprdk;

01 What inspired you to get into this business? Tn fuu jHdmdrhg fhduq ùSug fm<U jQ fya;= fudkjdo @ ePq;fs; ,e;j tpahghuj;Jiwapy; Eiotjw;F J}z;LNfhyhf ,Ue;jJ vd;d?

02 Did you face major obstacles in your business initially as a woman and how did you overcome them? jHdmdrh wdrïNfha È ldka;djla jYfhka Tng uqyQK §ug isÿjQ wjysr;d fudkjd o @ tu m%Yak Tn uev mj;ajd .;af;a flfiao@ ngz; vd;w tifapy; Muk;gf;fl;lj;jpy; cq;fs; tpahghuj;jpy; cq;fSf;F

Vw;gl;l jilfs; kw;Wk; mtw;iw ePq;fs; vt;thW ntw;wp nfhz;Bu;fs;?

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03 What competition did you face at the time of entry into the market and what were the strategies adopted by you to overcome competition? fj<|m<g we;=¿ùfï§ Tng uqyqK§ug isÿjQ ;rÕldÍ;ajh fln÷o @ iy tu ;rÕldÍ;ajh uevmj;ajd .ekSug .;a WmdhYS,s l%Shdud¾.hka fudkjdo@ Muk;gj;jpy; re;ijapy; vt;tifahd Nghl;b cq;fshy; Kfk;nfhLf;fg;gl;lJ?

mij ntw;wpnfhs;tjw;F cq;shy; filgpbf;fg;gl;l topKiwfs; vit?

04 Where do you see your business in three years from now? Tnf.a jHdmdrh oeka isg bÈß jir ;=kl ld,hlska olskafka fld;ko@ ,g;nghOjpypUe;J ,d;Dk; %d;W tUlq;fspy; cq;fs; tpahghu epiyia ePq;fs;

vt;thW Nehf;Ffpd;wPu;fs;?

05 You may attach one A4 Size page note on the vision of your company or any other information that you feel important such as provision of employment, recycling of waste, saving of foreign exchange etc, to further support your application. Tnf.a ±lau yd fjk;a úia;r Wod ( ^/lshd W;amdol wmøjH m%;spl%Slrkh úfoaY úksuh /ia lsÍu ms<sn| iúia;rd;aul úia;rhla ^ ;ks msgqjlg iSud jq A4 & fuu whÿïm; iu. bÈßm;a lrkak'cq;fs; tpahghuj;jpd; ,yf;Ffs;> my;yJ NtW Kf;fpa jfty;fs; mNj Nghd;W

cq;fshy; toq;fg;gl;l Ntiytha;g;Gfs;> fopT kPs;Row;rp Kiwfs;> ntspehl;L ehza

Nrkpg;G Nghd;w cq;fs; tpz;zg;gj;Jf;F Jiz Nru;g;gjw;F Fwpg;gpLtjw;fhf ePq;fs;

NyW jhnshd;iw gad;gLj;jyhk;

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Part VI– AUTHENTICATION 6 fldgi - iy;sl lsÍu gFjp 6-rhd;W gLj;jy;

I declare that all information furnished by me in my application is true and accurate. I am aware that the panel of judges have the right to disqualify my application if they are of the view any information furnished by me is false.

by; i|yka ish¿ f;dr;=re udf.a ±kqu mßÈ i;H yd ksjerÈ nj fuhska m%ldYlr isáñ' by; i|yka f;dr;=re j, hï wi;H;djhla we;akï ud kqiqÿiq whÿïlrejl= njg m;a lsÍug úksYaph uKav,hg iïmQ¾K whs;sh we;s njo fuhska i|yka lrñ'

,e;j tpz;zg;gj;jpy; vd;dhy; Fwpg;gplg;gl;Ls;s tpguq;fs; ahTk; rupahdit vd ,j;jhy;

cWjpg;gLj;Jfpd;Nwd;. ,e;j tpguq;fspy; VjhtJ cz;ikaw;wjhf ,Ug;gpd; eLtu;fspd;

FOtpduhy; vdJ tpz;z;ggk; epuhfupf;fg;gLk; vd;gij ehd;mwpNtd;.

Name: ku ngau;

Signature: w;aik ifnahg;gk;

Designation: ;k;=r gjtp

Company Rubber Seal iud.fï uqødj epWtd ,wg;gu; Kj;jpiu

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Witness 1: m,uq idCIslre cWjpnra;gtu; (rhl;rp)

Name ku ngau;

Signature w;aik ifnahg;gk;

N.I.C No. cd (ye(m(wxl( Nj.m.m.,y

Witness 2: fojks idCIslre

cWjpnra;gtu; (rhl;rp)

Name ku ngau;

Signature w;aik ifnahg;gk;

N.I.C No. cd (ye(m(wxl( Nj.m.m.,y