FORM NO.

GNL-1 Form for filing an application with

Registrar of Companies
[Pursuant to rule 12(2) of the Companies
(Registration offices and Fees) Rules,2014]

Form language English Hindi

Note - All fields marked in * are to be mandatorily filled.

1. * Category of applicant
Company
2. * Name of office of the registrar of Companies (RoC) to which application is being made
Registrar of Companies, Orissa
3. (a) Corporate identity number (CIN) or foreign company U01400OR2018PTC029698 Pre-fill
registration number (FCRN) of the company or RUN reference number
(Service request number (SRN) of RUN)
(b) Global location number (GLN) of company

4. (a) Name of the company KONKUWAN HERBS PRIVATE LIMITED

(b) Address of the

Madan Mohan Dutta Mohapatra C/o Baseli, Sahipuri
registered office or ORISSA
of the principal place Puri
of business in India Orissa
of the Company 752001
India
(c) e-mail ID of the company RO***********IL.COM

5. Details of applicant (in case category is others)

(a) Name

(b) Address Line I

Line II

(c) City

(d) State

(e) ISO country code

(f) Country
(g) Pin code

(h) e-mail ID
6. * Application filed for

Compounding of offences
Extension of period of annual general meeting by three months
Scheme of arrangement, amalgamation
Others
7. If Others, then specify
Request the Registrar of Companies to permit the cancellation of the mistakenly filed Form PAS-3 and MGT-14.
Also attached affidavit for the same.

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 8. * Details of application
An investment from IIM Calcutta Innovation Park in the form of debentures was supposed to come and, in good
faith, company has proceeded with the filing of Form PAS-3 and MGT-14, but the said funds were not received from
IIM Calcutta Innovation Park till now. As per the Companies Act, 2013, allotment of shares requires receipt of
consideration. Since no funds were received, the allotment could not be legally completed. So, the filings made are
not to consider and should be canceled.

9. In case of application for compounding of offences, provide the following details

(a) Whether application for compounding offence is filed in respect of

Company Director Manager or Secretary or CEO or CFO Other

(b) Number of person(s) for whom the application is being filed
(c) Details of person(s) for whom the application is being filed
(i) Category Director identification number (DIN) or Pre-fill
income-tax permanent account number
(income-tax PAN) or passport number

Name

(ii) Category DIN or income-tax PAN or passport number Pre-fill

Name

(iii) Category DIN or income-tax PAN or passport number Pre-fill

Name

(iv) Category DIN or income-tax PAN or passport number Pre-fill

Name

(v) Category DIN or income-tax PAN or passport number

Pre-fill

Name

(vi) Category DIN or income-tax PAN or passport number Pre-fill

Name

(vii) Category DIN or income-tax PAN or passport number Pre-fill

Name

(viii) Category DIN or income-tax PAN or passport number Pre-fill

Name

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 (d) Whether application is being filed

Suo-motu In pursuance to notice received from RoC or any other competent authority

(e) Notice number and date of notice

(f) Section for which application is being filed

(g) Brief particulars as to how the default has been made good

10. In case of application is made for extension of period of an AGM, mention financial (DD/MM/YYYY)

year end date in respect of which the application is being filed

11.(a) Service request number of Form MGT-14

(b) Date of passing special or ordinary resolution (DD/MM/YYYY)

(c) Date of filing form MGT-14 (DD/MM/YYYY)

12. Total amount of stamp duty paid or stamp paper

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Attachments List of attachments
Attach
1. Board Resolution
2. Scheme of arrangement, amalgamation Attach

3. * Detailed application
Attach
4. Copy of notice received from RoC or any
Attach
other competent authority

5. Other attachments - if any Attach

Remove Attachment
Verification
To the best of my knowledge and belief, the information given in this application and its attachments is correct and
complete.
I have been authorised by the Board of directors' resolution number NA dated 19/03/2025 (DD/MM/YYYY)
to sign and submit this application.
I am duly authorised to sign and submit this form.
To be Digitally signed by

Managing Director or director or manager or secretary or CEO or CFO (in case of an Roopali Digitally signed
by Roopali Dutta

Indian company or an authorised representative (in case of a foreign company) or Dutta

Mohapatra
Mohapatra
Date: 2025.03.27
16:50:01 +05'30'

other)
Designation Director
DIN of the director or Managing Director or; income-tax PAN of the manager
or authorised representative; or CEO or CFO Membership number 0*2*8*5*
Certificate by practicing professional
I declare that I have been duly engaged for the purpose of certification of this form. It is hereby certified that I have gone through
the provisions of the Companies Act, 2013 and rules thereunder for the subject matter of this form and matters incidental thereto
and I have verified the above particulars (including attachment(s)) from the original/certified records maintained by the Company/
applicant which is subject matter of this form and found them to be true, correct and complete and no information material to this
form has been suppressed. I further certify that:
i. The said records have been properly prepared, signed by the required officers of the Company and maintained as per the
relevant provisions of the Companies Act, 2013 and were found to be in order ;
ii. All the required attachments have been completely and legibly attached to this form
To be digitally signed by

Chartered accountant (in whole-time practice) or Cost accountant (in whole-time practice) or

Company secretary (in whole-time practice)

Whether associate or fellow Associate Fellow
Membership number

Certificate of practice number

Note: Attention is also drawn to provisions of Section 447, section 448 and 449 of the Companies Act, 2013 which
provide for punishment for fraud, punishment for false statement and punishment for false evidence respectively

Modify Check Form Prescrutiny Submit

For office use only:

eForm Service request number (SRN) eForm filing date (DD/MM/YYYY)

Digital signature of the authorising officer

This e-Form is hereby approved

Confirm submission
This e-Form is hereby rejected

Date of signing (DD/MM/YYYY)

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