[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.
ORIGINAL
Valid w.e.f.________________
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____________________
_____________ hereby {Complete address}
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
________________________
DUPLICATE
Valid w.e.f._______________
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__________________
_________________ hereby {Complete address}
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