Form for seeking prior approval of Central Government under section 2 of the Forest(Conservation) Act,1980 for Diversion of fresh forest area
(To be filled up by User Agency)
A. General Details
A-1. Project Details
  (i). Proposal No. : FP/MN/DISP/47595/2020   (ii). Name of Project for which Forest Land is required : Construction of Trevi Hospital   (iii). Short narrative of the proposal and Project/scheme for which the forest land is required : To make a 100 bedded general hospital along with cancer treatment facility, research work will include analysis of pattern of disease, treatment response and survival of the cancer patient   (iv). State : Manipur   (v). Category of the Proposal : Dispensary/Hospital   (vi). Shape of forest land proposed to be diverted : Non Linear   (vii). Estimated cost of the Project(Rupees in lacs) : 500   (viii). Area of forest land proposed for diversion(in ha.): 0.898   (ix). Non-forest land required for this project(in ha.): 0   (x). Total period for which the forest land is proposed to be diverted(in years): 60
A-2. Details of User Agency
  (i). Name : M/S TREVI HOSPITAL   (ii). Address1 : Meitei Langol   (iii). Address2 : NIL   (iv). State : Manipur   (v). District : Imphal West   (vi). Pin : 795004   (vii). Landmark : Langol ICAR   (viii). Email address :   (ix). Landline Telephone No. : 385-000000   (x). Fax No. : 385-000000   (xi). Mobile No. : 9862851881   (xii). Website (if any) : NIL   (xiii). Legal status of User Agency : Others
A-3. Details of Person Making Application
  (i). First Name: Rajkumari   (ii). Middle Name: Ibemu   (iii). Last Name: Devi   (iv). Gender: Female   (v). Designation: Managing Partner   (vi). Address 1: Singjamei Thongam Leikai   (vii). Address 2: NIL   (viii). State: Manipur   (ix). District: Imphal West   (x). Tehsil: Lamphelpat Sub-Division   (xi). Pin: 795008   (xii). Landmark: Daoji School   (xiii). Email Address:   (xiv). Landline Telephone No.: 385-000000   (xv). Fax No.: 385000000   (xvi). Mobile No.: 9862851881   (xvii). Copy of documents in support of the competence/authority of the person making this application to make application on behalf of the User Agency:
B. Details of land required for the Project
B-1. Details of proposal seeking prior approval of Central Government under the Act for diversion of forest land for the Project already submitted in the past
List of proposal submitted in Past Proposal Status. Proposal No. Moef File No. Area Proposed for Diversion(Ha.) Area Diverted(Ha.) Date of In-Principle Approval Date of Final Approval
B-2. Details of forest land proposed to be diverted
B-2.1 Details of Divisions involved
Details of Divisions involved Division Name Forest Land(ha.) Non-Forest Land(ha.)
1.Central Forest Division,Imphal0.8980
B-2.2 Details of Districts involved
District wise breakup District Name Forest Land(ha.) Non-Forest Land(ha.)
1.Imphal West0.8980
B-2.3 Village wise breakup
Villages wise breakup Village Forest Land(ha.) Non-Forest Land(ha.)
1Meitei Langol0.8980
Total 0.898 0
B-2.4 Component wise breakup
Component wise breakup Component Forest Land(ha.) Non-Forest Land(ha.)
1Main Building0.10210
2Doctors Quarter0.07430
3Nurses Quarters0.07430
42 Wheeler Shed0.04640
5Garage and Generator Room0.04520
7Hospital Building for Future expansion0.10210
8Parking and Passage0.43510
Total 0.898 0
C. Maps of forest land proposed to be diverted
Division 1. : Central Forest Division,Imphal
  (i). Area of forest land proposed to be diverted(in ha.) : 0.898   (ii). Nature of the Project: Non Linear   (a). No. of patches : One
Patch wise details
Patch No. Area of Patch(in ha.) Kml File of PatchesTo view KML file on google the same may be downloaded and then open if in google earth install in your computer.
1.0.898    View File
  (iii). Copy of Survey of India Toposheet indicating boundary of forest land proposed to be diverted:   (iv). Scanned copy of the Geo-referenced map of the forest land proposed to be diverted prepared by using GPS or Total Station:
D. Justification for locating the Project in forest land and details of alternatives examined:
  (i). Copy of note containing justification for locating the Project in forest land:
E. Employment likely to be generated
  (i). Whether the Project is likely to generate employment ?: Yes   (ii). Permanent/Regular Employment(Number of persons): 200   (iii). Temporary Employment(Number of person-days): 30
F. Displacement of People due to the Project, if any
  (i). Whether Project involves displacement?: No
G. Details of Cost-Benefit analysis for the Project
  (i). Whether the Project requires Cost-Benefit analysis?: Yes   (a). Copy of Cost-Benefit analysis:
H. Status of Environmental Clearance
  (i). Whether the Project requires Clearance under the Environment (Protection) Act 1986 ? : No
I. Status of Wildelife Clearance
  (i). Whether the Project or a part thereof is located in any Protected Area or their Eco sensitive zone? : No
J. Applicability of special provisions governing Scheduled Areas
  (i).Whether the Project or a part thereof is located in a Scheduled Area? : No
K. Status of settlement of rights under the Forest Rights Act,2006 on the forest land proposed to be diverted
  (i). Whether the process for settlement of Rights under the Forest Rights Acts 2006 on the forest land proposed to be diverted has been completed? : No
L. Details of land identified for Compensatory Afforestation
  (i). Whether non-forest or Revenue forest land is required to be provided by User Agency?: Not Applicable   (ii). Whether the area of non-forest land or Revenue forest land required to be provided by User Agency for raising Compensatory Afforestation is less than area of forest land proposed to be diverted ?: Not Applicable   (iii) . Reason for not providing Non-Forest Land: Not Applicable
Additional information Details
S.No Documents
1Undertaking for payment of NPV
2Undertaking for payment of Additonal NPV
3Undertaking for payment of Additonal CA and Penal CA