APPENDIX - 11H
APPLICATION FORM FOR GRANT OF DUTY FREE REPLENISHMENT CERTIFICATE
1. Please see paragraph 7.4 of the Policy and Paragraph 7.55 to 7.62 of this Handbook.
2. Please read the general instructions given at Appendix-1 before filling this application.
3. Please submit 2 copies of this application.
FOR OFFICIAL USE
File Number:----------------------------------------------- Date:---------------------
1. Name and address of the applicant : .......................................
2. I.E. Code No.: : .......................................
3. PAN Number : : .......................................
4. Export Product Group: : .......................................
5. Sr.No. of Standard Input-Output Norms: : .......................................
6. Total FOB value Rs.............. In currency ........... in US$ ...............
realised of exports
7. Total CIF value of Rs. ............ in currency ........... in US $ ..............
imports: of exports
8. Value addition:
9. Application fee a) Bank Receipt/ : ................................
Demand Draft No.and ................................
date
b) Rupees: ................................
................................
c)Issued by : ................................
10. Port of Export : ....................................................................
11. Details of the product exported (Resultant Products).
| S.No. | Resultant product | Total quantity | Unit of measurement | FOB value |
| Name, Technical Characteristics and quality | ITC(HS) Code | Name | Code | In rupees | In freely convertible currency (FCC) |
| | | | | | | | |
12. Details of Items sought to be Imported Duty free as replenishment.
| S.No. | Import item | Total quantity | Unit of measurement |
Name, Technical
characteristics
and quality | ITC(HS) Code | Name | Code |
| | | | | | |
13. Details of other materials used in resultant product and imported/ procured from sources other than
the licence.
| S.No | Resultant product(s)(Name, Technical characteristics and quality) | Total quantity | Imported item | Indigenously procured item |
| Name, Technical Characteristics and Quality | Quantity and unit of measure-ment | CIF value | Name, Technical Character-istics and Quality | Quantity and unit of measure-ment | Value |
| | | | | | | | | |
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 further declare that no export proceeds are outstanding beyond the prescribed period as laid
down by the RBI, 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.
Place : Signature of the Applicant: ........................
Date :Name: ........................
Designation: ........................
Official Address: ........................
........................
Tele No: ........................
E-Mail 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. EP copy of the Shipping Bill.
3. Bank Certificate of Export and Realisation as given in Appendix-25.
4. A statement of exports giving separately each Shipping Bill number and date, FOB value in Indian
rupees as per Shipping Bill and description of the resultant product