Note: 1. Please see Para 8.3 of the Policy and Para 8.11 of this Handbook 2. Please read the general instructions given at Appendix 1 before filling this application. ........................................................................... FOR OFFICIAL USE File No. :........................................... Date :............... ........................................................................... 1. Name and address of the Applicant :.................................. ................................... 2. IEC Number :.................................. 2(A)PAN Number :.................................. 3. Application for :................................... 4. FOB Value of export (US$) :................................... 5. CIF Value of licence applied for (US$) :.............................. 6. Application Fee : Rs............................... 7. Bank Recpt. / DD No. :.................................. Date :.............................. Issued by :................. 8. If the application is against specific Order, give; a) Export Order No. and Date :......................................... b) Name and address of foreign buyer :...................................... 9. Amount of Commission or discount, :......................................... if any : 10. Export performance in respect of cut and polished diamonds during the preceding three licensing years:

Against DTC Lic.	FOB(Year-1)	FOB(Year-2)	FOB(year-3)
others
			Total

11. Details of outstanding export obligation under Diamond / DTC Imprest Licences, if any

S. No.	Licence No. and date	CIF Value	FOB Value	Export Obligation fulfilled Valuwise	Expiry Date of Export Obligation Period

DECLARATION / UNDERTAKING ......................... 1. I / We hereby 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 therefrom. 2. I / We fully understand that any information furnished in the application if proved incorrect or false will render me / us liable for any penal action or other consequences as may be prescribed in law or otherwise warranted. 3. I / We undertake to abide by the provisions of the Foreign Trade (Development and Regulation) Act, 1992, the Rules and Orders framed thereunder, the Export and Import Policy and the Handbook of Procedures. 4. I / We declare that outstanding realisation of export proceeds beyond 180 days does not exceed 10% of average exports of preceeding three licensing years. I / We further declare that no export proceeds are outstanding beyond the period of one year or such extended period for which RBI permission has been obtained. 5. I hereby certify that I am authorised to verify and sign this declaration as per Paragraph 3.8 of the Policy. Signature of the Applicant :................. Name: ......................... Designation: ......................... Official Address: ......................... ......................... Tele.No.: Residential Address: ......................... Place : ......................... Date : Email Address :.......................... ....................................................................... Documents to be enclosed with the application form: ....................................................................... 1. Bank Receipt (in duplicate) / Demand Draft evidencing payment of application fee in terms of Appendix-34. 2. Self certified copy of Export Order. OR 3. Statement of exports of cut and polished diamonds made during the preceding three licensing years duly certified by Chartered Accountant / Cost and Works Accountant.The value exports made towards fullfilement of export obligation under Diamond Imprest licence shall be shown separately.