APPENDIX- 10D

APPLICATION FORM FOR GRANT OF DUTY FREE REPLENISHMENT CERTIFICATE

---

1. Please see paragraph 4.2 of the Policy and Paragraph 4.33 to 4.36 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.	Export Product Group	: .......................................
4.	S.No(s) of Standard Input Output Norms or wastage norms as per para 4.56 of Handbook for exports of gold/ silver/ platinum jewellery and articles thereof:	: .......................................

(Above Sl. No. 4 has been corrected vide PN No. 17/2002, Dt. 05/06/2002)

5.	Total FOB value	Rs..............	In currency ...........	in US$ ..................
	realised (including commission)		of exports
6.	Total CIF value of	Rs. ............	in currency ...........	in US $ ..............
	imports:		of exports

7. Value addition:

8. Application fee	a) Bank Receipt/ Demand Draft No.and date b) Rupees: c)Issued by :	: ..................................... ..................................... ..................................... ..................................... .....................................
9. Port of Export		: .......................................

10. Details of the product exported (Resultant Products).

S.No.	Resultant product			Total quantity	Unit of measurement		FOB value
	Description of export product	S.No.of SION	ITC(HS) Code		Name	Code	In rupees	In freely convertible currency (FCC)

11. Details of Items sought to be Imported Duty free as replenishment.

S. No	Import Item		Technical Characteristics (for sensitive items as per para 4.31 of Handbook)	Total Quantity	Unit of Measurement (U/M)
	Description	ITS(HS) Code			Name	Code

(Table at S.No 11. Appendix 10 D has been corrected vide PN. No. 12(RE-02), Dt. 2/5/2002)

12. Details of other materials used in resultant product and imported/ procured from sources other than the licence.

S.No	Resultant product(s)(description of export product)	Total quantity	Imported item			Indigenously procured item
			Description	Quantity and U/M	CIF value	Description	Quantity and U/M	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 9.9 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-29.

2. EP copy of the Shipping Bill. In case of exports through notified land Customs under paragraph 4.19, the Bill of export may be accepted in lieu of shipping bill.

3. Bank Certificate of Exports and Realisation as given in Appendix 22 or Foreign Inward Remittance Certificate (FIRC) in the case of direct negotiation of documents. In case of FIRC, a declaration from the exporter that the remittance is in respect of Shipping Bill(s) No ____________ dtd _________ shall also be furnished.

(Above S.No. 3. has been amended vide PN No. 25/2002-07, Dt. 17/07/2002)

[OLD
3. Bank Certificate of Export and Realisation as given in Appendix-22. ]

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