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

(Please tick appropriate box below)

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                        New Registration

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                        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

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(i)  Service provider

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(ii) Service recipient

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(b) Other person/class of persons

(i)  Input service distributor

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

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

(i)  Registration of a single premise

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(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 














































(viii)State/Union Territory 























(ix) PIN 























(x) Telephone Nos.:  























(xi) Fax No. 























(xii)E-mail Address 























(c) In case of application for Centralized Registration, furnish address of all the premises from where taxable services are provided or intended to be provided (FORMAT AS PER 5(b) ABOVE)


(d) In case of application for Input Service Distributor, furnish address of all the premises to which credit of input services is distributed or intended to be distributed (FORMAT AS PER 5(b) ABOVE)

6.         Address of the premises or office paying service tax under centralised billing or centralised accounting under sub-rule (2) and (3A) of rule 4 of the Service Tax Rules, 1994.

































































7.         Description of taxable services provided or to be provided by applicant


Description of service

Relevant clause of section 65 of the Finance Act, 1994, to be indicated, if possible







8.         Name, Designation and Address of the Authorized Signatory /Signatories:


I, ___________________________________________hereby declare that the information given in this application form is true, correct and complete in every respect and that I am authorized to sign on behalf of the Registrant.

(a) For new Registration:  

I would like to receive the Registration Certificate by mail / by hand/ E-MAIL

(b) For amendments to information pertaining to existing Registrant:

Date from which amendments are made: _______________

(Original existing Registration Certificate is required to be enclosed)

                                                (Signature of the applicant/authorized person with stamp)




(To be given in the event Registration Certificate is not issued at the time of receipt of application for Registration)

I hereby acknowledge the receipt of your Application Form

(a)   For new Registration

(As desired, the New Registration Certificate will be sent by E-MAIL/ mail/handed over to you in person on______________)

      (b) For amendments to information in existing Registration      (I hereby acknowledge receipt of original existing Registration Certificate)


                                                            Signature of the Officer of Central Excise
                                                                        (with Name & Official Seal)