Form - A

APPLICATION FOR SETTING UP OF SPECIAL ECONOMIC ZONE

(See rule 3)

I. Name and address of the

Undertaking in full (Block Letters)

Name of the Applicant _________________________________

Full Address _________________________________

(Regd. Office in case of limited _________________________________

companies & Head Office for _________________________________

others _________________________________

Pin Code _________________________________

Tel. No. _________________________________

Fax No. _________________________________

Permanent E-Mail Address _________________________________

Name and address of each _________________________________

of the Directors/Partners/

Promoters, as the case may be

II. Nature of the applicant Firm or Company:

(a) Public Limited Company

(b) Private Limited Company

(c) Proprietorship

(d) Partnership

(e) Others (please specify)

Note:-Copy of certificate of incorporation alongwith Article of Association and Memorandum in case

of companies and partnership deed in case of partnership firms may please be attached.

III. (i) Location of the proposed Special Economic Zone:

Whether the proposal is for –

(a) Special Economic Zone for Multi Product.

(b) Special Economic Zone for Specific Sector.

(c) Free Trade and Warehousing Zone.

(Tick [ ]as applicable)

IV. (a) Distance from the nearest Sea Port or Airport or Rail or Road head to the proposed Special

Economic Zone

(b) Indicate the area of the proposed Special Economic Zone (in hectares)

(c) Whether the applicant is owner of the land and the land is in his/its possession.

(d) In the case of lease hold land, name of the lessor and the lease conditions.

(e) If the land is not in ownership or possession, steps being taken for acquisition of land.

(f) Whether the area is contiguous or not or whether there is any thoroughfare?

V. Proposed Financial/Investment Details:

(i) Cost of Land.

(ii) Cost of proposed infrastructure, namely:

(a) Development of land.

(b) Boundary walls, roads, drainage, water supply, electricity, etc.

(c) Ready Built up factory premises.

(d) Port.

(e) Airport.

(f) Others, if any, give details.

(iii) Total Investments

VI. Means of Financing

a) Equity Capital

b) Term Loan

c) External Commercial Borrowings, if any, furnish details.

d) Any other source

Total

VII. Equity including Foreign Investment

(i)

$ Thousand) (Rs.lakhs)

(a) Authorized ________________ ________________

(b) Subscribed ________________ ________________

(c) Paid up Capital ________________ ________________

Note: If it is an existing company, please give the break up of the existing and proposed capital structure

(ii) Pattern of share holding in the paid-up capital (Amount in Rupees)

(Rs. in lakhs) (US $ Thousand)

(a) Foreign holding _____________ ___________________

(b) Non Resident Indian company / individual holding

(i) Repatriable _____________ ___________________

(ii) Non-repatriable _____________ ___________________

(c) Resident holding _____________ ___________________

(d) Total _____________ ___________________

VIII Development of identified area as Special Economic Zone: Give the following details:-

Area in hectares

(i) Total area proposed for development as Special Economic Zone.

(ii) Area proposed to be developed as processing area.

(iii) Development activities proposed in the processing area, namely: –

(a) site development,

(b) construction of boundary walls,

(c) construction of roads,

(d) installation of water supply and sanitation and sewage systems,

(e) power distribution system,

(f) telecom facilities,

(g) construction of factory buildings and warehouses.

(h) Any other activity which may be required in the processing area.

(iv) Area proposed to be developed as non-processing area.

(v) Activities proposed in the non-processing area, namely: -

(a) Residential.

(b) Commercial complex.

(c) Recreation facilities.

(d) Social amenities – give details.

(e) Others – specify.

(vi) Standards of operation and maintenance of the facilities proposed

IX. Indicate exports and direct and indirect employment likely to be generated during the first five year

period.

(Attach a Project Report outlining the economic and commercial viability of the proposal)

X. Has the applicant obtained any, Permission or Approval from Government of India for setting up any

other SEZ/s, if so, details may be given and/or whether any such application is pending consideration before the

State Government or Government of India?

XI. Has the applicant or any of his partners/Directors who are also partners/Directors of any other company

or its associate concerns are being proceeded against and have been debarred from getting any License or Letter

of Intent or Letter of Permission under the Foreign Trade (Development and Regulation) Act, 1992/Custom Act,

1962/Foreign Exchange Management Act, 1999/Central Excise Act, 1944.

Place :_________ Signature of the Applicant ____________________

Date :________ Name in Block Letters ____________________

Designation ____________________

Official Seal/Stamp_________________ Tel. No. ____________________

E-mail ____________________

Web-Site, if any ____________________

Full Residential Address ____________________

Note: Furnish 25 copies of the application with project report.

U N D E R T A K I N G

I/We hereby undertake to abide by the provisions of the Special Economic Zones Act, 2005 and rules and orders

made there-under.

I/We hereby declare that the above statements are true and correct to the best of my/our knowledge and belief.

I/We will abide by any other condition, which may be stipulated by the Government of India or the State

Government. I/We fully understand that any Letter of Approval granted to me/us on the basis of the statement

furnished is liable to cancellation or any other action that may be taken having regard to the circumstances of the

case if it is found that any of the statements or facts therein are incorrect or false. An affidavit duly sworn in

support of the above information is enclosed.

Place :_________ Signature of the Applicant ____________________

Date :________ Name in Block Letters ____________________

Designation ____________________

Official Seal/Stamp_________________ Tel. No. ____________________

E-mail ____________________

Web-Site, if any ____________________

Full Residential Address ____________________