SECOND SCHEDULE
FORM C
[Under Regulation 12 of the Insolvency and Bankruptcy Board of India (Insolvency Professionals) Regulations, 2016]

To
The Chairperson
Insolvency and Bankruptcy Board of India
Sub.: Application for recognition as an insolvency professional entity
Sir/Madam,
1. I, being duly authorized for the purpose, hereby apply on behalf of
Name
Address
for recognition as an insolvency professional entity under the Insolvency and Bankruptcy Board of India (Insolvency Professionals) Regulations, 2016, and enclose proof that I am authorized to make this application and correspond with the Board in this respect.

2. I, on behalf of
affirm that the applicant is eligible to be recognised as an insolvency professional entity.

3. I, on behalf of
hereby affirm that -

i. all information contained in this application is true and correct in all material respects,
ii. no material information relevant for the purpose of this application has been suppressed, and
iii. recognition granted in pursuance of this application may be cancelled summarily if any information submitted herein is found to be false or misleading in material respects at any stage.

4. If granted recognition, I, on behalf of
undertake to comply with the requirements of the Code, the rules, regulations or guidelines issued thereunder, and such other terms and conditions as may be imposed by the Board while granting the certificate of recognition or subsequently.

Yours faithfully,
Name
Designation
Place
Date

ANNEXURE TO FORM C

PART I
GENERAL


1. Name of the applicant:
2. Address of registered office and principal place of business of the applicant:
3. Corporate Identification Number (CIN)/ Certificate of Registration:
4. PAN:
5. Name, designation and contact details of the person authorized to make this application and correspond with the Board in this respect:
Name
Designation
Contact Details

PART II
DIRECTORS/ PARTNERS


1. Please state the details of all directors/ partners of the applicant:
Yours faithfully,
Name
Place
Date