APPENDIX-VI

(Refer clause 12)

FORM-3
APPLICATION FOR AMENDMENT IN TERMS OF REFERENCE
1 Details of Terms of Reference: Date of issue of ToR; MoEF&CC / SEIAA File No.; copy of ToR letter
2 Details of Product
Product / Activity Quantity Quantity Unit Mode of Transport / Transmission
(Capacity/Area) As per approved proposed of Product
ToR

- Unit:- (Tons per Annum(TPA), Mega Watt(MW), Hectares(ha), Kilo Liters per Day(KLD), Tons Crushed
per Day(TCD), Cubic Meter per Day, Kilometers(Km), Million Liters per Day(MLD), Others)
- Mode of Transport/Transmission of Product (Road, Rail, Conveyor Belt, Pipe Conveyor, Arial Ropeway,
combination of two or three modes, Others)
2 Details of Configuration
Plant / Equipment / Existing Proposed Final configuration Remarks if any
Facility Configuration Configuration after amendment

3 Reasons for the amendment in ToRs

4 Any Other Amendment required
Reference of Description as per approved Description as per Remarks
approved ToR ToR proposal

5 Documents to be attached
a. Upload Copy of revised Form-1
b. Upload revised pre-feasibility report
c. Upload Cover Letter duly signed by the project proponent or authorized person
d. Upload a copy of authorization duly signed by the project proponent in support of the person making this
application on behalf of the User Agency
e. Upload Additional File, if any
6 Undertaking
I hereby give undertaking that the data and information given in the application and enclosures are true to be best of
my knowledge and belief and I am aware that if any part of the data and information found to be false or misleading
at any stage, the project will be rejected and clearance given, if any to the project will be revoked at our risk and
cost. In addition to above, I hereby give undertaking that no activity / construction / expansion has since been taken
up.
Name; Designation; Company; Address

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