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

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

4. Import and Export Code Number:

5. Jurisdictional Central Excise/Service Tax Division:

6. Service Tax Registration Number/Service Tax Code:

7. Declaration: I/We hereby declare that-

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

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

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

3. Address of the Registered/Head Office with Telephone and Email :

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. Information regarding Bank Account (Bank, Address of Branch, Account Number) in which refund amount should be credited/to be deposited

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/partner- ship/Registered Private Limited Company/Registered Public Limited Company/Others (specify)] ST/22105, 22106, 22107, 22109, 22110, 22111, 22112, 22117/2014