FORM - F

CONSOLIDATED APPLICATION FORM for SETTING UP UNIT IN SPECIAL ECONOMIC ZONE

[Refer 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.

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. 

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 and

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 Ltd. Company

[Tick (.....) the appropriate entry] : Private Limited Company

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 dead 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/SERVICE ACTIVITY: 

(Including By-product/Co-products)

(If necessary, additional sheets may be attached)

(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 Liters)

(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

5. Requirement of Power                                                                                                                                     (in KVA) 

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

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)

(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

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 licence 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 Licence/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 are incorrect or false. 

An affidavit duly sworn in support of the above information is enclosed.

Name in_________________________________   Block Letters

Designation _____________________________

Official ______________

Seal/Stamp 

Tel. No.________________

E-mail________________

Web-Site, if any________________

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 (quantity)

(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.