AMEND FORM ST-1

[Application form for registration under Section 69 of The Finance Act,1994(32 of 1994)]
IDENTIFICATION OF BUSINESS REQUIRING REGISTRATION
Name of Applicant : SCREENLINE EMBELLISHERS INDIA PVT LTD
Address of the Applicant : NO. 252,BEHIND YOUNG BRAND APPAREL BUILDING, KATTUPUTHUR VILLAGE, UTHIRAMERUR TALUK,KANCHEEPURAM DISTRICT-603 107.

Details of Permanent Account Number(PAN) of the applicant

PAN Status :
Name of the Applicant(as appearing in PAN) :
Constitution Of applicant :
Name of Trustee/Proprietor/HUF :
Category of Registrant :
Nature of registration :
Taxable services provided :

Allotted
PAN : AAMCS0132N
SCREENLINE EMBELLISHERS (INDIA) PRIVATE LIMITED
Registered Private Limited Company
Service Recipient
Centralized Registration for more than one premises
Tour operator services

ADDRESS OF PREMISES FOR WHICH REGISTRATION IS SOUGHT

Name Of Premises/Building :
Road / Street / Lane :
Block / Taluk / Sub-Division /
Town :
City / District :
PIN :
Phone Number-2 :
Fax Number 2 :
Commissionerate :

YOUNG BRAND APPAREL

KATTUPUTHUR VILLAGE
KANCHEEPURAM DISTRICT
KANCHEEPURAM
603107

PONDICHERRY
(Puducherry)
Range : MADURANDAGAM-I

Flat / Door / Block No : 252

Village / Area / Lane : UTHIRAMERUR TALUK
Post Office : UTHIRAMERUR
State / Union Territory :
Phone Number-1 :
Fax Number-1 :
Email Address :
Division :

TAMIL NADU
9940478843
pradeep@ksaca.com
VILLUPURAM

In case of application for Centralized Registration,furnish address of all the premises from where taxable services are provided or intended to be provided
Name Of Premises/ BRANDIX-APSEZ
Building :
Road / Street / Lane : PUDIMADAKA ROAD
Block / Taluk / Sub- APSEZ
Division / Town :
City / District : VISAKHAPATTINAM
PIN : 531011
Phone Number-2 :
Fax Number-2 :
Premises Code :

Flat / Door / C-16

Block No:
Village / Area / ATCHUTAPURAM
Lane :
Post Office : ATCHUTAPURAM MANDAL
State / Union ANDHRA PRADESH
Territory :
Phone Number-1 9566173748
:
Fax Number-1 :
Email Address : pradeep@ksaca.com

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
Name Of Premises/ YOUNG BRAND APPAREL
Building :
Road / Street / Lane : UTHIRAMERUR-CHENGELPET
ROAD
Block / Taluk / Sub- UTHIRAMERUR TALUK
Division / Town :

Flat / Door / 252

Block No :
Village / Area / KATTUPUTHUR
Lane :
Post Office : UTHIRAMERUR

Page 1 of 2

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
City / District : KANCHEEPURAM
PIN : 603107
Phone Number-2 :
Fax Number 2 :
Premises Code :

State / Union TAMIL NADU

Territory :
Phone Number-1 7299950042
:
Fax Number-1 :
Email Address : pradeep@ksaca.com

NAME, ADDRESS AND PHONE NUMBER OF PROPRIETOR / PARTNER / DIRECTOR / TRUSTEES ALONG
WITH DETAILS OF AUTHORIZED SIGNATORIES
Name : NISHANTHA KUMARA
Designation : Director
Address : NO. 18/04, "SCREENLINE HOUSE", THALWATTE,GONAWALA,KELANIYA,SRILANKA
Phone Number : 7299950042
Email Address : pradeep@ksaca.com
Name : THANUJA DILHANI
Designation : Director
Address : NO. 18/04, "SCREENLINE HOUSE", THALWATTE, GONAWALA, KELANIYA,SRILANKA.
Phone Number : 7299950042
Email Address : pradeep@ksaca.com

NAME, DESIGNATION AND ADDRESS OF AUTHORIZED SIGNATORIES

Name : S. PRADEEP
Designation : Others
Address : No. 252, Young Brand Apparel Building, Kattuputhur Village, Uthiramerur Taluk, Kancheepuram
District-603 107.
Phone Number : 7299950042
Email Address : pradeep@ksaca.com

Declaration
I, S. PRADEEP,hereby declare that the information given in this application form is true,correct and complete in
every respect and that I am authorised 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:
Date : 15/09/2014

Page 2 of 2