Name and address of Operator/Licensee/Contractor :
4.
Sub-Contractor's Name & Address :
5.
No. & Date of sub-contract by Operator
(if any, copy to be attached) :
6.
Supplier's Name and Address :
7.
Ex-Works Address :
8.
PO/SO placed by Operator/Sub-Contractor (copy to be attached) :
9.
Call Out No., if any (copy to be attached) :
10.
Technical Write-up with justification for present purchase :
11.
If supply is under negative list, please attach permission from CCOE/DGFT/DGCA/AERB as the case may be :
12.
Import Content, If Yes Value with EC (INR), without EC (INR) :
With EC(INR)
Without EC(INR)
13.
Particulars of Essentiality Certificate(s) already obtained for execution of the above contract (Statement is enclosed) :
14.
Whether items of supply is by Operator on behalf of Joint Venture or in Individual Capacity or by Sub-Contractor :
15.
Specified place/destination of use of items of present supply :
16.
Office of the concerned Central Tax/State Tax commissionerate
(Under Jurisdiction of recipient of outward supply of goods) :
It is certified
(a)
(b)
that the present procurement is within the approved work programme and budget.
DECLARATION/UNDERTAKING
1.
2.
3.
I/We will furnish to the Authorities necessary undertakings and affidavits as required in terms of the aforesaid Notification at the time of clearance of the goods.
4.
I/We will comply with all policies, Hand-Book of Procedures and Public Notices issued from time to time.
5.
"I/We declare that the particulars and the statements made in this application are true and correct to the best of my/our knowledge and belief and nothing has been concealed or held there-from."
6.
I/We will furnish a certified statement to DGH on end-use of all items procured for which ECs obtained in terms of above Notification on a yearly basis till such goods are finally utilised/consumed.
7.
The present case is not an ex post facto case i.e. physical supply of materials will be effected only after obtaining EC from DGH.
8.
I also declare that I am authorized to sign the application for the grant of exemption certificate.
Date:
Name of Signatory :
Place:
Designation :
Signatory User Name:
Address :
Tel No. :
Fax No. :
Email ID :
Notes :
1.
Delete which ever is not applicable.
2.
All pages of applications with List of Goods in duplicate, as per Format in Annexure-A, to be sealed & signed with date by the authorised signatory of the Operator/Licensee/Contractor.
Please Select Purpose Of Goods:
Please Select Currency Type:
