APPENDIX-IX

(Refer clause 17)

FORM-6
APPLICATION FOR GRANT OF PRIOR ENVIRONMENT CLEARANCE
(Where any lease or license or right or permission or authorization granted by the Government in respect
of a project or activity is cancelled in any legal proceedings or by Government in accordance with law and
the said lease or license or right or permission or authorization in respect of that project is granted to any
other person or successful bidder and there is no specific enactment on the aforesaid subject under any law
for the time being in force)
1 Name of the Project (s)
2 Details of Earlier Project Proponent: Name of the Company / Organisation; Registered Address; Legal Status of
the Company; details of Joint Venture if any; etc.
3 Details of New Project Proponent: Name of the Company / Organisation; Registered Address; Legal Status of the
Company; details of Joint Venture if any; etc.
4 Address for the correspondence: Name of the applicant; Designation (Owner / Partner / CEO); Address; Pin code;
e-mail; Telephone No.; Fax No.; etc.
5 Category of the Project/Activity as per Schedule: Item under schedule; Category (A/B1/B2)
6 Details of Prior Environmental Clearance: Date of issue of Prior environmental clearance; MoEF&CC / SEIAA
File No.; copy of prior-EC letter
7 Details of Consent to Establishment: Whether Consent to Establishment obtained (Yes/No); If yes, copy of
Consent to Establishment obtained including that valid till date; Date of issue; Validity; File No.; Application No.;
etc.
8 Status of Implementation of the project vis-à-vis approved mining plan (form mining projects) or feasibility
report (other projects)
9 Revised Environmental Management Plan
10 Documents to be attached
a. Copy of letter of allocation
b. Covering letter duly signed by the project proponent or authorized person
c Copy of authorization duly signed by the project proponent in support of the person making this application
on behalf of the User Agency
d. Copy of earlier EIA Report based on which Prior-EC was granted to earlier project proponent
e. Additional documents, if any
11 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.
Name; Designation; Company; Address

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