--:: SURAT SPECIAL ECONOMIC ZONE ::--

Form-F

CONSOLIDATED APPLICATION FORM for -
(See rule 17)

Setting up of units in Special Economic Zone;

Annual permission for sub-contracting;

Allotment of Importer Exporter Code Number;

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

Water Connection;

Registration-cum-Membership Certificate;

Small Scale Industries Registration;

Registration with Central Pollution Control Board;

Power connection;

Building approval plan;

Sales Tax registration;

Approval from Inspectorate of factories;

Pollution control clearance, wherever required;

Any other approval as may be required from the State Government

The application should be submitted to the Development Commissioner of the concerned Special Economic Zone in 5 copies alongwith a crossed Demand Draft of Rs. 5,000/- 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	__	__	/	__	__	/	__	__	__	__
	Date			Month			Year

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)
	Name of the applicant Firm/company	____________________
	Full Address (Regd. Office in case of Limited Companies & 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 & a/c No.	____________________
	Income Tax PAN (attach copy)	____________________

II.	Constitution of the applicant firm: (Please click/tick the appropriate entry)
	Government Undertaking	[ ]
	Public Limited Company	[ ]
	Private Limited Company	[ ]
	Proprietorship	[ ]
	Partnership	[ ]
	Others (Please Specify)	[ ]
(Attach copy of the certificate of incorporation alongwith Article of Association and Memorandum in case of companies and Partnership deed in case of partnership firms)

III.	Nature of the industrial undertaking: (Please click/tick the appropriate entry)
	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 No.
Sl.No.	Name	Address	Telephone No.
1.	____________________	____________________	____________________
2.	____________________	____________________	____________________
3.	____________________	____________________	____________________
4.	____________________	____________________	____________________
5.	____________________	____________________	____________________
6.	____________________	____________________	____________________


V.	ITEM(S) OF MANUFACTURE/SERVICE: (Including By-product/Co-products) (If necessary, additional sheets may be attached)
Item(s) Description		Capacity (Unit = [ ] )	Item Code (ITC HD Code No.) (Note required for service unit)
____________________		____________________	____________________
____________________		____________________	____________________
____________________		____________________	____________________
____________________		____________________	____________________
____________________		____________________	____________________
____________________		____________________	____________________
____________________		____________________	____________________


VI.	INVESTMENT
		Rs. In lakhs	US $ thousand
a)	Plant and machinery		____________________
	i) Indigenous		____________________
	ii) Imported (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 lakhs)
		Import	Indigenous
	a) Capital goods	____________________	____________________
	b) Raw material, components, consumables, packing material, fuel etc for 5 years	____________________	____________________
	Total	____________________	____________________
(Give details in project report, namely list of capital goods, description of raw materials, and other inputs, etc)

VIII	INFRASTRUCTURE REQUIREMENTS
		Requirement of Land:-		(Area in sq. mtrs.)
	1.	i.	Factory & Officers	____________________
		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	____________________
	5.	Requirement of Power (in KVA)		____________________

IX	Employment	Men	Women
IX	Employment

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 Investment
1.		($ in thousand)	(Rs. In lakhs)
i)	a) Authorised	____________________	____________________
	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
		(Rs. In lakjs)	(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 Commercial Borrowing (Give details)	____________________	____________________
2.	Technical Collaboration (Furnish details in project report
		(Gross of taxes – Rs. In lakhs)
	a) Lumpsum payment	____________________
	b) Design & Drawing Fee	____________________
	c) Payment to foreign technician	____________________
	d) Royalty (on exports)	____________________ %
	e) Royalty (On domestic tariff Area if envisaged)	____________________
	f) Duration of agreement	____________________ Years
3.	Marketing Collaboration (Furnish details in project report)

XI. FOREIGN EXCHANGE BALANCE SHEET

		1st Year	2nd Year	3rd Year	4th Year	5th Year	Total
		1st Year	2nd Year	3rd Year	4th Year	5th Year	Rs. Lakhs	US$ Thous.
1.	FOB Value of exports in first five years	[ ]	[ ]	[ ]	[ ]	[ ]	[ ]	[ ]
2.	*Foreign Exchange outgo 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, lump sum know-how fee, design and drawing fee, payment of foreign technicians, payment on training of India 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/LOP under EOU/SEZ/STP/ EHTP scheme. If so, please give full particulars especially reference number, date of issue, items of manufacture and progress of implementation of each project	____________________
(ii)	Whether the applicant or any of the partners/Directors who are also partners/Directors of another company or its associate concerns are being proceeded against or have been debarred from getting any Lincese/letter of Intent/Letter of Permission under the Export and Import (Control) Act, 1947/Foreign Trade (Development and Regulation) Act, 1992/FEMA/Custos/Central Excise Act.	____________________

Place	____________________	Signature of the applicant
Date	____________________	Name in Block Letters	____________________
Official Seal/ Stamp	____________________	Designation	____________________
		Tel No.	____________________
		E-Mail address	____________________
		Website, 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 will abide by any other condition, which may be stipulated by the concerned Development Commissioner. I/We fully understand that any Permission Letter 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	____________________
Official Seal/ Stamp		Designation	____________________
		Tel No.	____________________
		E-Mail address	____________________
		Website, if any	____________________
		Full Residential Address	____________________

Note: Format 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	____________________
	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	____________________

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