Service Tax-FORM A-3

FORM A-3

DECLARATION FOR OBTAINING SERVICE TAX CODE

[Refer clause (c) under paragraph 3]

1. Name of the SEZ Unit/Developer:

2. Address of the SEZ Unit/Developer with Telephone and Email:

3. Address of the Registered/Head Office:

4. Permanent Account Number(PAN) of the SEZ Unit/Developer:

5. Import and Export Code Number:

6. Jurisdictional Central Excise/Service Tax Division:

7. Service Tax Registration Number/Service tax Code:

8. Details of Bank Account ( Bank, Address of Branch, Account Number)

9. (a) Constitution of SEZ Unit/Developer [ proprietorship/partnership/Registered Private Limited Company/Registered Public Limited Company/Others(specify)]
     (b) Name, Address, Telephone number of Proprietor/partner/director(s)

10. Name, designation and address of the authorised signatory/signatories

11. I/We hereby declare that-

    (i) The information given in this application form is true, correct and  complete in every respect and that I am authorised to sign on behalf of the SEZ Unit/Developer;

    (ii) I/We shall maintain proper account of specified services as approved by the Approval Committee of SEZ, received and used for authorised operations in SEZ; and shall make available such accounts and related records, at all reasonable times, to the Department for inspection or scrutiny.

    (iii) I/We shall use/have used specified services for authorised operations in the SEZ.

Signature and Name of Authorised Person with stamp

Date:

Place: