APPLICATION FORM FOR PROVISONAL REGISTRATION OF STP/CCP UNITS (I)Application for Provisional registration Section 1: Company Profile Section2 : Financial Details Section3 : Manpower Section4 : Infrastructure Section5 : Product Details Section6 :Declaration Check list of important documents to be submitted along with this form. Page 1 of 8 APPLICATION FOR PROVISIONAL REGISTRATION OF STP/CCP UNITS Proposal for : (Please tick whichever appropriate) 1. Establishment of a New Undertaking: a) STP b) CCP 2. Expansion of existing Unit 3. Conversion of an Existing Unit : a) Hardware to Software b) Software to Hardware 1. Name of Company/ Firm/Individual : 2. Existing Company / New Company : (Enclose supporting document/s) 3. No. & Date of Registration of Co./Firm : 4. Sales Tax Registration no. : 5. Permanent Account Number (PAN): 6. Registered Office : (Enclose supporting document/s) a) Address : b) Tel. : Fax : c) E-mail : d) Official Website : http://www. 7. Office of the Unit : a) Address : b) Tel. : Fax : c) E- mail : 8. Contact Person : a) Name : b) Designation : c) Tel. (O) : ( R ) : d) E -mail : Fax : 9. Head of the Organisation : a) Name : b) Designation : c) Tel. (O) : ( R ) : d) E -mail : Fax : 10. Legal Status of the Organisation : (Please tick whichever appropriate) 1) Private Sector Undertaking 2) Individual Promoter 3) Partnership 4) Other ( Please specify details along with supporting documents) Note: - Copy of certificate of incorporation along with Article of Association and Memorandum in case of companies and partnership deed in case of partnership firms may please be attached. Name of Proprietor/ Partners/Directors Shares in the Firm/Co. Permanent Address Tel./Fax Nos. 9.1. CAPITAL STRUCTURES FOR PROPOSED COMPANY: (Rs. Lacs) Type of Equity Existing Proposed Authorized capital Subscribed capital Paid-up capital 9.2. PATTERN OF SHARE HOLDING IN THE PAID UP CAPITAL: (Rs. Lacs) Existing: Foreign Holding (a) NRI Company/ Individual holding (b) Indian (c) Commercial Borrowings (d) Direct (A) Indirect (B) Repatriable (A) Non-Repatriable (B) Internal External Total: (A+B) Total: (A+B) Any other Source(e): Total Investment: a + b+ c + d + e: Proposed: Foreign Holding (a) NRI Company/ Individual holding (b) Indian (c) Commercial Borrowings (d) Direct (A) Indirect (B) Repatriable (A) Non-Repatriable (B) Internal External Total: (A+B) Total: (A+B) Any other Source(e): Total Investment: a + b+ c + d + e: 10. Revenue details for next five years (in lacs) : 11. Have you entered into/envisaged any foreign collaboration (Technical or marketing or consultancy? If so please fill up following details: ( a ) Name of the foreign collaborator ( b ) Address (s) : Phone Fax : E-Mail : Telex : ( c ) Country : ( d ) Nature of Foreign Collaboration: ( e ) Proposed duration of agreement for which royalty will be restricted : 1st Year 2nd Year 3rd Year 4th Year 5th Year Export Domestic TOTAL 12. Staff & labor (existing and proposed) to be employed in the implementation of the project Type Existing Proposed Year NG G Ist 2nd 3rd 4th 5th 1)Managerial 2)Supervisory Technical A) Hardware B) Software Non - Technical 3) Clerical 4)Labour A)Skilled B)Semi-Skilled C)Unskilled Other Categories Total: * NG = Non Goan G =Goan. 13.Infrastructure details Existing Proposed Land Built-up space (Sq. Mtrs.) Total Power requirement (KVA) Back-up Power (KVA) Water requirement (Cu. Mtrs. Per month) Data Link Connectivity (KBPS Leased Line) Telephone Lines (Nos) Other requirement (if any ) 14. Source of Power (Private/Government/Generators): 15. Details of Plant & machinery (Including Computers, workstations) : 16. Details of Raw Material : Sr. No. Indigenous Specifications 1. 2. 3. 4. 5. Imported Specifications 1. 2. 3. 4. 5. Sr. No. Indigenous Specifications 1. 2. 3. 4. 5. Imported Specifications 1. 2. 3. 4. 5. 17.Area of Expertise: (Please tick whichever appropriate) a) System Software Development b) System Software Conversion c) Design and implementation of management Information system and decision support system d) Financial control and accounting system e) Production management and inventory Control f) Project feasibility studies and project monitoring systems g) Microprocessor based software h) Communication Software i) CAD/CAM/CIM/FEA j) Expert system k) Back office/Remote Data Entry l) Application Re-Engineering m) BPO n) If any other , please specify : 18. Products Details Sr. No Name of the Products Specifications 1. 2. 3. 4. 5. The information furnished by Me/Us in this form is true to the best of my knowledge and belief. Date: Signature of Authorized Signatory Place: Name: Designation: Stamp of Co. / Firm: I declare and undertake that the project is being set up / has been set up in the below mentioned premises. Name of the Building / Premises : Located at : House/Plot No. : Floor No. : Occupied Partly/Fully : Built up area (sq. mtrs) : Carpet area ( sq. mtrs) : Solely owned by : Taken on lease : No. of Years .... from date......... to date........ ( Enclose Copy of lease) ** I, further declare and undertake that the construction is legal and obtained all licenses/approvals / occupancy certificate as per the requirement of local authorities and no part of the said premises is illegally or unauthorizedly constructed or under any dispute. Date: Signature of Authorized Signatory Place: Name: Designation: Stamp of Co. / Firm: ** Note: Please note incase of leased premises, obtain declaration and undertaking from the owner or lessor of the premises on similar lines.
