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Form St-1 - Application Form For Registration Under Section 69 Of The Finance Act, 1994 Page 2

(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

(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

(ix) PIN

(x) Telephone Nos.:

(xi) Fax No.

(xii)E-mail Address

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)

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.

Address

Description of taxable services provided or to be provided by applicant

S.No.

Description of service

Relevant clause of section 65 of the Finance Act, 1994, to

be indicated, if possible

(1)

(2)

(3)

Form St-1 - Application Form For Registration Under Section 69 Of The Finance Act, 1994 Page 2