[Application form for registration under Section 69 of the Finance Act, 1994 (32 of 1994)]

(Please tick appropriate box below)

                        New Registration

                        Amendments to information declared by the existing Registrant.

Registration Number in case of existing Registrant seeking Amendment  _____________

1.         (a) Name of applicant  

            (b) Address of the applicant 

2.              Details of Permanent Account Number (PAN) of the applicant

(a) Whether PAN has been issued by the Income Tax Department    

      Yes  No

(b)   If Yes, the PAN                 

(c)  Name of the applicant (as appearing in PAN)                           

3.         (a) Constitution of applicant (Tick as applicable)

(i)      Proprietorship

 (ii)    Partnership                                                           

(iii)   Registered Public Limited Company

(iv)  Registered Private Limited Company        

(v)    Registered Trust

(vi)  Society/Cooperative society

(vii) Others

            (b) Name, Address and Phone Number of Proprietor/Partner/Director

            (i)  Name

            (ii)  Address

            (iii) Phone Number

4.         Category of Registrant (Please tick appropriate box)

(a) Person liable to pay service tax

(ii) Service recipient

(b) Other person/class of persons

(i)  Input service distributor

(ii) Any provider of taxable service whose aggregate value of taxable
    service in a financial year exceeds three lakh rupees    

5.         (a) Nature of Registration (Tick as applicable)

(i)  Registration of a single premise

 

(ii) Centralized Registration for more than one premises

(b) Address of Premises for which Registration is sought

            (i)  Name of Premises / Building

(ii) Flat/Door/Block No.               

(iii)   Road/Street/Lane 

           (iv) Village / Area / Lane 

           (v)  Block/Taluk/Sub-Division/Town 

(vi) Post office 

(vii)City/District 

(viii)State/Union Territory