Form - F

CONSOLIDATED APPLICATION FORM for –

(See rule 17)

1. Setting up of units in Special Economic Zone;

2. Annual permission for sub-contracting;

3. Allotment of Importer Exporter Code Number;

4. Allotment of land/industrial sheds in the Special Economic Zone;

5. Water Connection;

6. Registration-cum-Membership Certificate;

7. Small Scale Industries Registration;

8. Registration with Central Pollution Control Board;

9. Power connection;

10. Building approval plan;

11. Sales Tax registration;

12. Approval from Inspectorate of factories;

13. Pollution control clearance, wherever required;

14. Any other approval as may be required from the State Government.

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1. The application should be submitted to the Development Commissioner of

the concerned Special Economic Zone in 5 copies alongwith a crossed Demand

Draft of rupees five thousand drawn in favour of The Pay & Accounts Officer

of the concerned Special Economic Zone together with a project report

giving details of activities proposed.

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For Official Use only

Application No. ______________________________

Date: ______________________________

Details of Bank Draft

Amount Rs. ___________________

Draft No. ___________________

Draft date ___________________

Drawn on ___________________

(Name of the Bank)

Payable at ____________________

PART - I

I. Name and full address of applicant firm/ _______________________

company (in block letters)

Registered Office in case of limited _______________________

company & Head Office for _______________________

others) _______________________

Pin Code _______________________

Tel. No. _______________________

Fax No. _______________________

Permanent E-Mail Address _______________________

Web-Site, if any _______________________

Passport No., if any _______________________

Name of Bank with Address & Account No. _______________________

Digital Signature _______________________

Income Tax PAN _______________________

(attach copy)

II. Constitution of the applicant firm: Public Limited Company

[Tick (v ) the Private Limited Company

appropriate entry] Partnership

Proprietor ship

Others (please specify)

(Attach copy of Certificate of Incorporation alongwith Articles of

Association and Memorandum of Association in case of companies and

partnership deed in case of partnership firms.)

III. Nature of the industrial undertaking

i. Large scale

ii. Medium scale

iii. Small scale

IV. Name and complete address of each ____________________________

Of the Directors/Partners/Proprietor,

as the case may be with

Telephone numbers

V. ITEM (S) OF MANUFACTURE/SERVICEACTIVITY:

(Including By-product/Co-products)

(If necessary, additional sheets may be attached)

Item(s) Description Capacity(Unit = )

(Not required for service unit)

________________ ________________

________________ ________________

________________ ________________

VI. INVESTMENT: (RS. IN LAKHS)

(a) Plant and Machinery

________________________

(i) Indigenous ________________________

(ii) Import CIF value ________________________

(iii) Total (i) + ii) ________________________

(b) Details of source(s) of finance

VII. Import and indigenous requirement

of materials and other inputs:

(Value in Rupees)

Import Indigenous

a) Capital Goods

b) Raw material, components, consumables,

packing material, fuel etc. for 5 years

(Give details in project report,

namely list of Capital Goods, description

of raw materials, and other inputs, etc).

TOTAL: -----------------------

-----------------------

VIII. INFRASTRUCTURE REQUIREMENTS

1. Requirement of land: - (Area in sq. mtrs.)

i. factory & offices

ii. Warehousing/storage

iii. Others, specify

2. Requirement of built-up area

3. Requirement of Water (in Kilo Litres)

i. For industrial (process) purposes

ii. For drinking purposes

iii. Others, specify

iv. Total requirement

4. Effluent Treatment

i. Quantum and nature of effluents and mode of disposal

ii. Specify whether own Effluent Treatment Plant

will be created

(in KVA)

5. Requirement of Power

IX. EMPLOYMENT

Men Women

_____________ _____________

X. WHETHER FOREIGN TECHNOLOGY AGREEMENT IS ENVISAGED

(Tick ( \/ ) the appropriate entry)

Yes ____________ No_____________

(i) Name and Full Address of foreign collaborator

(ii) Nature of Collaboration

1. Equity Participation including Foreign Investment

(i) ($ in thousand) (Rs. in lakhs)

(a) Authorized ________________ ________________

(b) Subscribed ________________ ________________

(c) Paid up Capital ________________ ________________

Note: If it is an existing company, give the break up of 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 Equity _____________ ___________________

(e) External commer- ______________ ___________________

cial Borrowing

(give details)

2. Technical collaboration

(furnish details in project report)

(Gross of Taxes)

(a) Lumpsum payment _____________________

(b) Design & Drawing fee _____________________

(c) Payment to foreign technician _____________________

(d) Royalty (on exports) ____________________%

(e) Royalty ____________________

(on domestic tariff area sales if envisaged)

(f) Duration of agreement ______(Number of years)

3. Marketing collaboration

(furnish details in project report)

XI. Foreign Exchange Balance sheet

Total Total

1st 2nd 3rd 4th 5th (5 yrs)

Rs. In lakhs/$ in thousand

1. FOB value of

exports in first

five years

2. * Foreign Exchange

outgo on for the

first five years

3.

Net Foreign

Exchange earnings

For the first five

years (1) – (2)

* Foreign exchange outgo shall include the CIF value of import of

machinery, raw material, components, consumables, spares, packing materials

and amount of repatriation of dividends and profits, royalty, lumpsum

knowhow fee, design and drawing fee, payment of foreign technicians,

payment on training of Indian technicians abroad, commission on export,

interest on external commercial borrowings, interest on deferred payment

credit and any other payments.

XII. OTHER INFORMATION

i) Whether the applicant has been issued any _________________

Industrial license or LOI/LOA under EOU/SEZ/_______________

STP/EHTP scheme. If so, _______________

give full particulars, namely reference number,

date of issue, items of manufacture and

progress of implementation of each project.

ii) Whether the applicant or any of the _________________

partner/Director who are also partners _________________

/Directors of another company or firms its

associate concerns are being proceeded

against or have been debarred from

getting any License/Letter of Intent/

Letter of Permission under Foreign Trade

(Development and Regulation) Act, 1992 or

Foreign Exchange Management Act, 1999 or

Customs Act, 1962 or 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_________________

UNDERTAKING

I/We hereby declare that the above statements are true and correct to the

best of my/our knowledge and belief. I/We shall abide by any other

condition, which may be stipulated by the Development Commissioner. I/We

fully understand that any Permission Letter/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 furnished 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 Full Official address _________________

_________________

Seal/Stamp __________________Tel. No. _________________

e-mail Address _________________

Web-Site _________________

Full Residential address ________________

_________________

Tel. No __________________

Note: Formats of application not given herein may be obtained from the

Development Commissioner.

PART - II

If sub-contracting is envisaged in the

manufacturing operations, furnish

following details:

i. Sub-contracting permission is required for -

(a) part of the production process (quantify)

(b) any particular production process (give

details)

ii. Name and address and other particulars

of sub-contractor and whether the sub-

contractor is

(a) Domestic Tariff Area unit/Central Excise

Registered or otherwise

(b) Other Special Economic Zone unit

(c) Export Oriented unit or Electronic Hardware

Technology Park unit or Software Technology Park unit.