[See rule 68(K)]

COUNTER FOIL

Circle____________

Serial A.No. (Seal of issuing Authority)

Date of issue

Name & address of regd.

Dealer to whom issued. _____________________

TIN .:___________________

Valid w.e.f. _____________

I,_________________________

(proprietor/partner)

(Full Name)

Karta of Joint Hindu Family/Managing Director or

Director authorised by the Board of Directors of the

Limited company/President or Secretary of the

Society , Club, or Association/Head of the office or

Officer duly authorized by the Head of the Office of

The ____________________ Department of The Government of______________________

Principal Officer or officer duly authorized by the Principal officer of the Authority or the Body Carrying on business under the name and style of Sarvasri_____________________

the principal place of business whereof is situated at

_____________________ hereby {Complete address}

Declare that the goods of the description mentioned

Below are being imported by our firm

Discription _______________ Qty._______ Purchase from M/s._______________________

Against bill/cash memo/challan No.________ dated _____ for Rs._______(enclosed with the duplicate copy of this declaration No. of form "C" if issued

_______________________

I do hereby declare that the information given above

is true and correct to the best of my knowledge and belief .

Strike out whichever is not applicable.

[See rule 68(K)]

ORIGINAL

Circle____________

Serial A.No. (Seal of issuing Authority)

Date of issue

Name & address of regd.

Dealer to whom issued. _____________________

TIN .:___________________

Valid w.e.f.________________

I,_________________________

(proprietor/partner)

(Full Name)

Karta of Joint Hindu Family/Managing Director or

Director authorised by the Board of Directors of the

Limited company/President or Secretary of the

Society , Club, or Association/Head of the office or

Officer duly authorized by the Head of the Office of

The _____________________ Department of The Government of_______________________

Principal Officer or officer duly authorized by the Principal officer of the Authority or the Body Carrying on business under the name and style of Sarvasri____________________

the principal place of business whereof is situated at

_____________ hereby {Complete address}

Declare that the goods of the description mentioned

Below are being imported by our firm

Discription_______________ Qty._______ Purchase from M/s.________________________

Against bill/cash memo/challan No.________ dated ______ for Rs._______(enclosed with the duplicate copy of this declaration No. of form "C" if issued

________________________

I do hereby declare that the information given above

is true and correct to the best of my knowledge and belief .

Strike out whichever is not applicable.

[See rule 68(K)]

DUPLICATE

Circle____________

Serial A.No. (Seal of issuing Authority)

Date of issue

Name & address of regd.

Dealer to whom issued. _____________________

TIN .:___________________

Valid w.e.f._______________

I,_________________________

(proprietor/partner)

(Full Name)

Karta of Joint Hindu Family/Managing Director or

Director authorised by the Board of Directors of the

Limited company/President or Secretary of the

Society , Club, or Association/Head of the office or

Officer duly authorized by the Head of the Office of

The __________________ Department of The Government of ____________________

Principal Officer or officer duly authorized by the Principal officer of the Authority or the Body Carrying on business under the name and style of Sarvasri__________________

the principal place of business whereof is situated at

_________________ hereby {Complete address}

Declare that the goods of the description mentioned

Below are being imported by our firm

Discription_________________ Qty._______ Purchase from M/s.________________________

Against bill/cash memo/challan No.________ dated ______for Rs._______(enclosed with the duplicate copy of this declaration No. of form "C" if issued

________________________

I do hereby declare that the information given above

is true and correct to the best of my knowledge and belief .

Strike out whichever is not applicable.