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Form St-1 - Application Form For Registration Under Section 69 Of The Finance Act, 1994 Page 3

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

DECLARATION

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)

Date:

Place:

ACKNOWLEDGEMENT

(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)

Date:

Form St-1 - Application Form For Registration Under Section 69 Of The Finance Act, 1994 Page 3