Note: 1. Please see Para 9.2(c ) of this Handbook. 2. Please read the general instructions given at Appendix-I before filling this application and also some important guidelines given at the end of this application. ------------------------------------------------------------------------------- The application should be submitted to the concerned Development Commissioner of the Export Processing Zone alongwith a crossed Demand Draft of Rs. 1,000/- drawn in favour of the Pay & Accounts Officer, Department of Industrial Development, Ministry of Industry, payable at the Sate Bank of India, Nirman Bhavan, New Delhi. ------------------------------------------------------------------------------- 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 ________________________ I. NAME AND ADDRESS OF THE PROMOTER/INDUSTRIAL UNDERTAKING IN FULL (Block Letters) Name of the Undertaking/Applicant __________________________ Full Address __________________________ (Regd.Office in case of limited __________________________ companies & Head Office for __________________________ others __________________________ Pin Code __________________________ Tel. No. __________________________ Fax No. __________________________ E-Mail No. __________________________ II. NATURE OF THE APPLICANT FIRM: (Please tick bthe appropriate box) 1. Government Undertaking 2. Public Limited Company 3. Private Limited Company 4. Proprietor ship 5. Partnership 6. Others (please specify) III. (1) Location of the proposed undertaking Full Address __________________________ Pin code __________________________ (Rs. In lakhs) -------------------------------------------------------------------------------------------- IV INDICATE BROAD ETAILS Imports Export Local OF THE PRODUCTS/SERVICE purchase ACTIVITIES FOR WHICH UNIT IS PROPOSED IN A PERIOD OF FIVE YEARS --------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------- (1 $=Rs.)

	Rupees (lakhs)	US $ (Thousand)
1st year
2nd year
3rd year
4rd year
5th year
Total :

V. INVESTMENT: (RS. IN LAKHS) (a) Land ________________________ (b) Building ________________________ (c) Plant and Machinery ________________________ (i) Indigenous ________________________ (US $ Thousand) (ii) Import CIF value ________________________ (iii) Total (I) + ii) ________________________ VI. 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 separately. (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(a+b(i+ii)+c equity _____________ ___________________ (e) (iii) External commercial Borrowing ________________ FOREIGN EXCHANGE BALANCE SHEET IX. EMPLOYMENT (All figures in number ) Existing Proposed -------------- ------------------------ a) Supervisory _____________ _______________ b) Non-supervisory _____________ _______________ X. OTHER INFORMATION i) Any special features of the :............................ project proposal which you want :............................ to highlight :............................ :............................ (please attach the project report, :............................ for new units) ii)(a) Whether the applicant has been :............................ issued any industrial license or :............................ LOI/LOP under EOU FTZ/EPZ scheme :............................ if so, please give full particulars :............................ especially reference number, date :............................ of issue, items of manufacture and progress of implementation of each project. (b) Whether the applicant has submitted :............................ any other application for LOI/LOP :............................ which is pending with the Board of :............................ Approvals. If so, please give :............................ particulars like reference number, :............................ name under which application made, items of manufacture etc. (iii) Whether the applicant or any of the :............................ partners / Directors who are also :............................ partners / Directorsof another :............................ company or its associate concerns :............................ have been debarred from getting any :............................ License/Letter of Intent/ Letter of Permission under the Export and Import(Control) Act. 1947/ Foreign Trade (Development and Regulation)Act, 1992 or otherwise penalized. Place :_________ Signature of the Applicant ____________ Date :________ Name in Block Letters ____________ Designation _____________ Official Seal/Stamp Full Official Address :..................................... ...................................... ...................................... 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. Place:__________ Signature of the Applicant_______ Date:___________ Name in Block Letters____________ Designation ____________ Official Address Seal/Stamp __________________ Official ______________ Residential ______________ Address: ___________________

		1st	2nd	3rd	4th	5th	Total 5 Yrs In Rs./lakhs	Total 5 Yrs In Th US
VII.	FOB value of exports in first five years
VIII.	Foreign Exchange outgo on
(i)	Import of machinery
(ii)	Import of raw materials and components/spares/consumables
(iii)	Repatriation of dividends and profits to foreign collaborators
(iv)	Commission on Export etc.
(v)	Any other payments (specify details)
	Total (i) to (v)
	Foreign Exchange Earnings in 5 years