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(viii)State/Union Territory 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

Text Box:  

 

(i)  Service provider

Text Box:  

(ii) Service recipient

Text Box:  

(b) Other person/class of persons

(i)  Input service distributor

Text Box:  

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

Text Box:  

 

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

(i)  Registration of a single premise

Text Box:  

 

(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