Form - A APPLICATION FOR SETTING UP OF SPECIAL ... - SEZ India

Form - A 

APPLICATION FOR SETTING UP OF SPECIAL ECONOMIC ZONE 

(See rule 3) 

I. Name and address of the 

Undertaking in full (Block Letters) __________________________________________ 

Name of the Applicant) 

__________________________________________ 

Full Address) 

__________________________________________ 

(Regd. Office in case of limited 

companies & Head Office for _________________________________________ 

others 

Pin Code 

_________________________________ 

Tel. No. 

_________________________________ 

Fax No. 

_________________________________ 

Permanent E-Mail Address _________________________________ 

Name and address of each _________________________________ 

of the Directors/Partners/ 

Promoters, as the case may be 

II. Nature of the applicant Firm or Company: 

(a) Public Limited Company 

(b) Private Limited Company 

(c) Proprietorship 

(d) Partnership 

(e) Others (please specify) 

Note:-Copy of certificate of incorporation alongwith Article of Association and 

Memorandum in case of companies and partnership deed in case of partnership firms 

may please be attached. 

III. (i) Location of the proposed Special Economic Zone: 

Whether the proposal is for – 

(a) Special Economic Zone for Multi Product. 

(b) Special Economic Zone for Specific Sector. 

(c) Free Trade and Warehousing Zone. 

(Tick [ ]as applicable) 

1

IV. 

2 

(a) Distance from the nearest Sea Port or Airport or Rail or Road head to the 

proposed Special Economic Zone 

(b) Indicate the area of the proposed Special Economic Zone (in hectares) 

(c) Whether the applicant is owner of the land and the land is in his/its possession. 

(d) In the case of lease hold land, name of the lessor and the lease conditions. 

(e) If the land is not in ownership or possession, steps being taken for acquisition 

of land. 

(f) Whether the area is contiguous or not or whether there is any thoroughfare? 

V. Proposed Financial/Investment Details: 

(i) Cost of Land. 

(ia) Type and quality of land i.e. waste and barren land, 

single crop or double crop etc. 

(ii) Cost of proposed infrastructure, namely: 

(a) Development of land. 

(b) Boundary walls, roads, drainage, water supply, electricity, etc. 

(c) Ready Built up factory premises. 

(d) Port. 

(e) Airport. 

(f) Others, if any, give details. 

(iii) Total Investments 

VI. Means of Financing 

a) Equity Capital 

b) Term Loan 

c) External Commercial Borrowings, if any, furnish details. 

d) Any other source 

Total 

VIA. Foreign Direct Investment (FDI) 

(a) Extent of FDI (if any) in million U.S. Dollars 

(b) Source of FDI (Country and Company details may be provided)”; 

3

3 

VII. 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 

(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 ____________ ________________ 

VIII. Development of identified area as Special Economic Zone: Give the following 

details:- 

Area in hectares 

(i) Total area proposed for development as Special Economic Zone. 

(ii) Area proposed to be developed as processing area. 

(iii) Development activities proposed in the processing area, namely: – 

(a) site development, 

(b) construction of boundary walls, 

(c) construction of roads, 

(d) installation of water supply and sanitation and sewage systems, 

(e) power distribution system, 

(f) telecom facilities, 

(g) construction of factory buildings and warehouses. 

(h) Any other activity which may be required in the processing area. 

4

4 

(iv) Area proposed to be developed as non-processing area. 

(v) Activities proposed in the non-processing area, namely: - 

(a) Residential. 

(b) Commercial complex. 

(c) Recreation facilities. 

(d) Social amenities – give details. 

(e) Others – specify. 

(vi) 

Standards of operation and maintenance of the facilities proposed 

IX. 

Indicate exports and direct and indirect employment likely to be generated during 

the first five year period. 

(Attach a Project Report outlining the economic and commercial viability of the 

proposal) 

X. Has the applicant obtained any, Permission or Approval from Government of 

India for setting up any other SEZ/s, if so, details may be given and/or whether any such 

application is pending consideration before the State Government or Government of 

India? 

XI. Has the applicant or any of his partners/Directors who are also partners/Directors 

of any other company or its associate concerns are being proceeded against and have 

been debarred from getting any License or Letter of Intent or Letter of Permission under 

the Foreign Trade (Development and Regulation) Act, 1992/Custom Act, 1962/Foreign 

Exchange Management Act, 1999/Central Excise Act, 1944. 

Place :_________ 

Signature of the Applicant ____________________ 

Date :________ Name in Block Letters ____________________ 

Designation 

Tel. No. 

____________________ 

____________________ 

Official Seal/Stamp____________ E-mail. ____________________ 

Web-Site, if any 

____________________ 

Full Residential Address ____________________ 

5

5 

U N D E R T A K I N G 

I/We hereby undertake to abide by the provisions of the Special Economic Zones Act, 

2005 and rules and orders made there-under. 

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 Government of India or the State Government. I/We fully understand that any 

Letter of Approval 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 ____________________ 

Designation 

Tel. No. 

____________________ 

____________________ 

Official Seal/Stamp____________ E-mail. ____________________ 

Web-Site, if any 

____________________ 

Full Residential Address ____________________ 

6

6 

Check List 

1. Name of the Developer. 

2. Proposed area of the location of the SEZ. 

3. Status of recommendation of the proposal by the State Government (if available). 

4. Whether proposal is for formal or in-principle approval? (In case land is in possession 

of the promoter, it is considered for formal approval) 

5. Is it a multi-product SEZ? 

6. If it is a sector specific SEZ, the sector is. 

7. Whether it meets the area requirements. 

8. Area of the SEZ (in hectares) 

9. Whether Form- A has been filed? 

10. Whether undertaking and affidavit has been submitted? 

11. Whether project report has been submitted? 

12. Whether land is owned/leased and is in possession of the Developer? 

13. Does the proposal meet the area requirements of the Rules? 

14. Whether the land has existing structures or is vacant? 

15. Whether the land is contiguous? 

16. Projected investment in the project. 

17. Projected exports from the project. 

18. Projected employment from the project. 

19. Share capital and Reserves of the Developer Company. 

20. Source of funds for the project. 

21. Net worth of the Applicant (including Group companies) duly supported by Audited 

Accounts of the Developer for last 3 Years (for all the constituents in case the Developer 

is a SPV). If the company is a new company, audited accounts of Flagship 

Company/promoters may be provided. 

22. Extent of FDI (if any) in million U.S. Dollars 

23. Source of FDI (Country and Company details may be provided) 

24. Whether provisions contained in the Press Note No. 5 (2005 Series), issued by the 

Ministry of Commerce and Industry have been followed in respect of Telecom/IT SEZ 

development?

Form - A APPLICATION FOR SETTING UP OF SPECIAL ... - SEZ India

Create successful ePaper yourself

Delete template?

Save as template?