KARNATAKA TAX ON PROFESSIONS, TRADES, CALLINGS AND EMPLOYMENTS RULES, 1976 - FORMS
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FORM 1-A

[See Rules 3(1), 4(1) and 6(2)]

COMBINED APPLICATION FORM

The Registering Authority......................

..................I,........................Son/Daughter/Wife of.....................on behalf of the dealer carrying on business whose particulars are given below hereby apply for registration under Section 10 of the Karnataka Sales Tax Act, 1957 and Section 4 of the Karnataka Tax on Entry of Goods Act, 1979 and Section 5 of the Karnataka Tax on Professions, Trades, Callings and Employments Act, 1976.

1.	Name of the dealer with Trade Name and full Postal Address:	(i) Registered/Corporate Office:
		Tel:	Fax:	E-mail:
		(ii) Local Office:
		Tel:	Fax:	E-mail:
2.	Full Address of the Factory:
		Tel:	Fax:	E-mail:
3.	Name and address of the person applying for Registration and his/her status:
4.	Name, Address, Telephone No. and details of the Proprietor/Partners/Directors and others with details of immovable property possessed by the proprietor/individual partners/firm/company and others:

Name	Status	Date of Birth and Age	Father's Name/Husband Name/Wife Name	Present address	Residential address
(1)	(2)	(3)	(4)	(5)	(6)

Permanent address	Telephone No. Off./Res.	Fax/E-mail	Description of building/land	Extent of interest in the business
(7)	(8)	(9)	(10)	(11)

Details of immovables

Survey No. (for land) House No.	Extent	Location/address	Ownership (Exclusive/Joint)	Name and address and Telephone No. Of witness, who should be able to identify these persons
(12)	(13)	(14)	(15)	(16)

4(a) Category of the Chief Promoter: NRI/Woman/SC/ST/BC/Minority.

5. Details of head of the Unit/Applicant/Authorised Signatory:

Sl. No.	Name	Designation	Residential Address	Tel: (O)	Fax/E-mail
(1)	(2)	(3)	(4)	(5)	(6)

6.	Constitution of the Firm/Company	:	Proprietorship/Partnership/Private Limited/Other, if any
7.	Scale/size of business	:	SSI/Medium/Large
8.	Name of the products proposed to be manufactured/Services offered	:

Sl. No.	Products/By-products/Services	Installed Capacity (per annum)
1.
2.
3.
4.
5.

(Rs. In lakhs)

9.	Proposed investment	:	Land Building P&M Wkg. Capital Total
10.	Extent of land	:	Own Agricultural...............Sq. Mtrs./Ft.
			Industrially converted.........Sq. Mtrs./Ft.
			KIADB-Applied.................Sq. Mtrs./Ft.
			Allotted..............................Sq. Mtrs./Ft.
			Rented................................Sq. Mtrs./Ft.
11.	Expected date of commencement of production/business	:
12.	Power requirement	:	KPTCL Captive Generation Others, Total
			if any
13.	Water requirement	:	Industrial use......................K.ltrs.
			Domestic use......................K.ltrs.
			Total water requirement per day.......K. ltrs.
14.	Proposed employment	:
15.	Expected annual turnover	:
16.	Particulars of PRC/PMT/ITM/LT/IL (Copy to be enclosed):

No. and Date	Issuing Authority	Validity period
(1)	(2)	(3)

17. Particulars of all other places of business/sales outlets/branches/godowns/warehouses etc.:

Sl. No.	Type of business (Branches/godowns/warehouses, etc.	Name and full Address	Tel. No.	Fax	E-mail
(1)	(2)	(3)	(4)	(5)	(6)
1.
2.
3.

Details of branches, godowns,sales outlets outside the State of Karnataka, with full address and Telephone Numbers

18. Type of business:

(i)	Manufacturer	:
(ii)	Services	:
(iii)	Others	:

19. Particulars of Bank Account:

Sl. No.	Bank	Branch	Address	A/c. No.
(1)	(2)	(3)	(4)	(5)
1.
2.
3.

20. Particulars of maintenance of accounts:

(a) Language used	: English/Kannada/Hindi/Others
(b) Accounting year	: Jan-Dec/Apr-Mar/Jul-Jun/Any other period
	: Monthly/Qrty./H. Yly./Yly

21. Description of scheduled goods likely to be dealt in under the KTEG Act

22. Particulars of any other business in which Proprietor/Partner/Director etc.having interest at present and in the past:

Name and full address of the Business	KST Regn. No.	Capacity in which interested	In case of past interest date of relinquishing the position
	No.:
	Date:
	Circle:

23. Class of Employer:

i.	Individual
ii.	Partner
iii.	Firm
iv.	Company
v.	Corporation
vi.	Others (specify)

24.	No. Of workers engaged in the factory:	:
25.	No. Of employees in the establishment:	:
26.	Details of business premises and if shared with others, the details of other dealer with name, address, style of business and KST R.C. No.	:
27.	Details of antecedents of the dealer as Proprietor/Partner/Director, should indicate whether they were in business earlier as employees, partner, proprietor, etc. And date of relinquishing the post, closure of business, etc.	:
28.	Whether copies/orginals of following documents are filled	:
		Yes/No Details (Name of the Department)

1.	Ration Card	:
2.	Census	:
3.	Form 26	:
4.	Date of Birth	:
5.	Purchase deed/sale or lease deed of business premises	:
6.	Rental details of business	:
7.	Lease deed	:
8.	Partnership deed	:
9.	Memorandum of articles	:
10.	Licence obtained from any other department connected with the business (Licence/Account No. of Income-tax, Central Excise, State Excise, Shops and Establishments, etc.)	:
11.	Is the applicant connected with any other business present/past	:
12.	Two copies of recent passport size photograph of the person signing and verifying the application to be affixed	:

29.	Details of enrolment under the KTPTC and E Act, 1976 (to be filled in by the Registering Authority
30.	The names and address of two respectable persons in the applicants area whom the department may contact to Ascertain his standing and status

Name	Office Address and Phone No.	Residential Address and Phone No.
1.
2.

31. Enclosed DD/Crossed cheque/Treasury challan for Rs...........bearing No.............of Bank/Treasury..................towards registration and for Rs....................bearing No.............of Bank/Treasury towards Enrollment.

32. Reference No.......................of approval by the SHLCC/SLSWCC/DLSWCC

DECLARATION

I, .......................... Son/Daughter/Wife of.......................hereby declare that to the best of my knowledge and belief the information furnished in this application are ture and correct. In case any information is proved to be incomplete and untrue I would be liable for legal consequences thereof.

Name and Address and Signature of the person signing with status and relationship to the dealer (here state whether Proprietor, Manager, Director, Partner,etc.)

Place:
Date:	Signature.