Before the Customs and Central Excise Settlement Commission

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....i) Telephone No. 4. (i) Permanent Account No: (ii) Service Tax registration No: (iii) Status: ( See note 2 ) 5. (i) Commissioner of Central Excise/Service Tax having jurisdiction over the applicant: (ii) Postal address of the Commissioner of Central Excise/Service Tax having jurisdiction over the applicant: 6. Details of Show Cause Notice issued to the applicant (a) Show Cause Notice No and date (b) Period of dispute in the notice (c) Service tax demanded in the notice (in Rs.) (d) Dispute in connection with which the application for settlement is made. (e) Adjudicating authority before whom the notice is pending adjudication. 7. (i) Whether service tax returns were filed for the period o....

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....and date of the order (f) Reference number and date of the order, if any, in case the applicant was convicted of any offence under Chapter V of the Act in relation to a case settled earlier by the Settlement Commission 12. (i) Details of the order, if the applicant was ever debarred from making further application for settlement under section 32-O of Excise Act made applicable to Service Tax vide section 83 of the Act, by any of the Benches of the Settlement Commission (ii) Details of the order, if any settlement in respect of the applicant has ever been made void under section 32L of Excise Act made applicable to Service Tax vide section 83 of the Act, by any of the Benches of the Settlement Commission Signature of the ....

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.... accept cheques, drafts, hundies or other negotiable instruments. 2. Please state whether individual, Hindu undivided family, company, firm, an association of persons, etc. 3.  Details of the additional amount of Service Tax accepted as payable and interest thereon referred to in item 9 of the application shall be furnished in annexure to this application. 4.  Original copy of the of the TR-6 challan indicating amount of service tax accepted as payable for settlement and interest thereon referred to in item 9 be retained by the applicant, duplicate be endorsed to the Central Excise Officer having jurisdiction over the applicant, triplicate be endorsed to the jurisdictional Chief Accounts Officer of the Central E....