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DGFT Hand Book of Procedures Forms & Appendix (01/04/2003 to 31/08/2004) APPENDIX - 16A

APPENDIX - 16A
APPLICATION FORM FOR GRANT OF EXPORT LICENCE FOR EXPORT OF SPECIAL CHEMICALS , ORGANISMS, MATERIALS , EQUIPMENTS & TECHNOLOGIES ( SCOMET) ITEMS MENTIONED AS RESTRICTED FOR EXPORT IN APPENDIX-3 SCHEDULE 2 OF ITC(HS) CLASSIFICATIONS OF EXPORT AND IMPORT ITEMS

Note:- (1) Please read the general instructions at Appendix 1 before filling this application.

(2) Please submit 10 copies of this application form.

For official use

File No .................................................... Date.....................................................

Part-I

1.	Name and address of the Applicant	:
2.	IEC Number	:
Part-II (To be filled in for export of Special Chemicals in categories 1 B and 1 C Chemicals of Appendix 3 )
3.	(i) Item of export	:
	(ii) Quantity applied for	:
	(iii) fob value per unit	:
	(iv) total fob value	:
4.	Details of the exports of category 1B and 1C items in preceding three licensing years, where licence / permission / general permission has been taken
( for I B Chemicals )

Sl No.	DGFT, HQ File No	Permission letter Date	Items of export	Qty of items exported	FOB value in US $	Name of Buyer	Name of end-user	Destinations of Export	Shipping Bill No & date *	Bill of entry *
1	2	3	4	5	6	7	8	9	10	11

* Enclose copy of Shipping Bills and corresponding Bills of Entry serial-wise/ consignment-wise and on reverse of the same give details of DGFT permission letter No & date and Export Licence No & date , for the last three licensing years. To be enclosed with the first application of licensing year and thereafter for subsequent applications the File No of the first application be mentioned above.

Sl No.	DGFT, HQ File No	Permission letter Date	Export Licence No & date	Items of export	Qty	Total FOB value in US $	Name of Buyer	Name of end-user	Destination of Export	Bill of entry No *
1	2	3	4	5	6	7	8	9	10	11

* Enclose copy of Bill of Entry serial-wise/consignment-wise and on reverse of the same give details of DGFT permission letter No & date and Export Licence No & date, for the last three licensing years. To be enclosed with the first application of licensing year and thereafter for subsequent applications the File No of the first application be mentioned above.

5.	If applied for export on repeat basis in the same licensing year for same product and end-use and to the same end-user then following information may also be furnished	:
	(i) Reference No and date vide which the earlier permission was granted by this office	:
	(ii) Export Licence No and date	:
	(iii) Quantity allowed for export	:
	(iv) Quantity exported on the date of this application	:
6.	Export Order No & date ( Attach copy )	:
7.	Name and full address of the buyer	:
8.	Name and full address of the end-user	:
9.	Port of shipment	:
10.	Destination of Export	:
	(i) Port of discharge	:
	(ii) Ultimate destination	:
11.	End-product for which the item of export will be used by the end-user ( attach end-user certificate)	:
12.	The purpose for which the end-product will be utilised	:
13.	State if any licence has been denied in previous three licensing years	:
Part-III (To be filled in for export of all other category of items of Appendix 3 except those covered by Part-II above)
14.	Category , item number and item name as in Schedule 2 Appendix 3 of ITC(HS) Classification of Export and Import Items ( Attach technical specification not exceeding one page for item, in the order in which these items have been listed).	:
15.	(i)Quantity applied for	:
	(ii) Fob value per unit ( US $ )	:
	(iii)Total fob value ( US $)	:
16.	Importer’s Purchase Order No & date ( Attach copy )	:
17.	Is the applicant the producer / manufacturer of the item to be exported ? If not, name the producer / manufacturer and provide full address , telephone No. , etc.	:
18.	Details of Export Licences ( EL ) previously applied for items Schedule 2 Appendix 3 of ITC(HS) Classification of Export and Import Items	:

Sl No.	DGFT, HQ File No	Permission letter Date	Export Licence No & date	Items of export	Qty	Total FOB value in US $	Name of Buyer	Name of end-user	Destination of Export	Bill of entry No **	Status of fulfilment of other conditions , if any prescribed
1	2	3	4	5	6	7	8	9	10	11	12

** Enclose copy of Bill of Entry serial-wise / consignment-wise and on reverse of the same give details of DGFT permission letter No & date and Export Licence No & date, for the last three licensing years . To be enclosed with the first application of licensing year and thereafter for subsequent applications the File No of the first application be mentioned above.

19.	Port of shipment ( Sea and air ports of Delhi / Calcutta/ Chennai /Mumbai / and sea ports of JNPT and Nava Sheva-Identify only one port)	:
20.	Destination of export ( Country )	:
21.	Name of the consignee, complete postal address , telephone No, fax , etc.	:
22.	Citizenship of consignee ( if individual )	:
23.	Headquarters address of consignee , if corporate office different from entry (10 above)	:
24.	(a) Location ( country ) of end-user	:
	(b)End product and /or and purpose for which the exported item will be used by the end-user ( Attach end-use certificate in the prescribed proforma )	:
	(c)Name and complete address of end-user ( include tel Nos., fax Nos , etc. )	:
	(d)Is end-user an entity of Government of destination country?	:
	(e)Manufacturing / Business / Other activity of the end-user.	:
25.	Through which banks will the financial transactions relating to this export will be executed ?	:
	(a)In destination country ( provide full address )	:
	(b)In India	:
26.	Name and address of all foreign collaborators of the applicant ( as registered with GOI/RBI) . If None, state None	:
27.	Period during which the item is proposed to be exported from India	:
28.	If application is for spares or originally exported . Reference of earlier may be given	:
29.	If revalidation required	:
	(a)Period of extension sought	:
	(b)Reasons therefor	:
30.	State if any licence has been denied in previous three licensing years.	:

Declaration / Undertaking

I/We solemnly undertake that:-

Place:
Date:

Signature of the Applicant...................................
Name in Block letters...................................
Designation...................................
Official Address...................................
Residential Address...................................
E-mail Address...................................

END USE CUM END USER CERTIFICATE

I /we ( name of the end user)..................................................................... Certify that we are importing ( name of the SCOMET item ).................................................................. From (name and address of the exporter ).................................................................................... Against our purchase order No ........................ date ................................... as capital equipment/ Component / raw material / other use ( specify )...................................................... For the manufacture of ( end product ) ................................................... which will be used for (state specific use )* .........................................................

( * if more than one use then enclose self certified list )

I/we further certify that that the items detailed in the referenced purchase order will not be used for any purpose other than the purpose (s) stated above, and that such use shall not be changed nor the items modified or replicated without the prior consent of the Government of India. And further , if required , post installation verification shall be allowed.

The end-user shall not himself , or through another , cause the items , or replicas , ore derivatives thereof to be re-transferred / sold without the knowledge / consent of the Government of India, to any party within ( name of the country )___________________________________/ or outside it.

I/we also certify that all the facts contained in this certificate are true and correct to the best of my knowledge and belief and that I/we do not know of any additional facts that are inconsistent with this certificate

Place:
Date:

_____________________________________
Signature of end-user / authorised signatory
of the end-user with stamp and seal
Name :_____________________________
Designation :________________________
Address & e-mail :____________________

CERTIFICATION ON BEHALF OF THE RECEPIENT STATE

( For Schedule 3 Chemicals of CWC , viz . Category 1 C of SCOMET list)

( To be filled for transfers of Schedule 3 Chemicals to states not party to the Convention )

It is hereby certified that the transferred Chemical referred to above will be used only for purposes not prohibited / disallowed under the Chemical Weapons Convention and shall not be transferred to any other person or re-exported from the recipient country .

Name of the chemical ( IUPAC nomenclature)

Quantity

Signature:_________________________
Name:____________________________
Position:__________________________
Organisation / State:________________
Address:__________________________

IMPORT CERTIFICATE TO BE ACCOMPANIED WITH END-USE CUM END-USER CERTIFICATE

( To be filled when the import is by a third party )

I /we ( name of the end user ) ..................................................................... Certify that we are importing ( name of the SCOMET item ) ..................................................................... From (name and address of the exporter ) ..................................................................... Against our purchase order No ................................. date ................................... as capital equipment and which will be transferred to : .......................... in .............................. (country ) for the manufacture of ( end product) ..................................................................... which will be used for ( state specific use ) ..................................................................... ( the end use cum end user certificate from the ultimate end user is also enclosed ) as component and will be used for assembling of another equipment .................................... and will be transferred to ........................................ in ................................. (country ) for the manufacture of (end product ) ..................................................................... which will be used for ( state specific use ) ..................................................................... ( the end use cum end user certificate from the ultimate end user is also enclosed ) .......................................... will be used as raw material for the manufacture of (end product ) ....................................................... and will be transferred to ........................................ in ......................................... (country ) which will be used for ( state specific use ) ..................................................................... ( the end use cum end user certificate from the ultimate end user is also enclosed ) which will be used for purposes other than the above ( specify )

(Please refer PN. NO. 74/2003, DT. 06/08/2004 for amendment in the revised Appendix 16-A )

(NB : export of 1C Chemicals shall be allowed only when buyer and end-user are in the same country)

I/we further certify that that the items detailed in the referenced purchase order will not be used for any purpose other than the purpose (s) stated above, and that such use shall not be changed nor the items modified or replicated without the prior consent of the Government of India. And further , if required , post installation verification shall be allowed.

The end-user shall not himself , or through another , cause the items , or replicas , ore derivatives thereof to be re-transferred / sold without the knowledge / consent of the Government of India, to any party within ( name of the country )____________________________________/ or outside it.

I/we also certify that all the facts contained in this certificate are true and correct to the best of my knowledge and belief and that I/we do not know of any additional facts that are inconsistent with this certificate and am also enclosing the end use cum end user certificate

Place:
Date:

Signature of end-user / authorised signatory
of the end-user with stamp and seal
Name :____________________________
Designation:_______________________
Address & e-mail:___________________

Name of the chemical ( IUPAC nomenclature)

Quantity

Signature:_________________________
Name:____________________________
Position:__________________________
Organisation / State:_________________
Address:__________________________

(Above Appendix - 16A has been amended vide PN. No. 39/2003, DT. 28/01/2004)

APPENDIX - 16A
APPLICATION FORM FOR GRANT OF EXPORT LICENCE FOR EXPORT OF SPECIAL CHEMICALS, ORGANISMS, MATERIALS, EQUIPMENTS AND TECHNOLOGIES (SCOMET) ITEMS MENTIONED AS RESTRICTED FOR EXPORT IN APPENDIX-3 SCHEDULE 2 OF ITC(HS) CLASSIFICATIONS OF EXPORT AND IMPORTS ITEMS

Note:: 1. Please read the general instructions given at Appendix 1 before filling this application.

2. Please submit 5 copies of this application form.

FOR OFFICIAL USE

File No.:--------------------------------

Date:-----------------------

PART-I

1.	Name and address of the Applicant	:
2.	IEC Number	:

PART-II
(To be filled in for export of Special Chemicals in Categories 1B and 1C of Appendix-3)

3.	(i) Item of export	:
	(ii) Quantity applied for	:
	(iii) FOB value per unit	:
	(iv) Total FOB Value	:
4.	Details of the exports of category 1B and 1C Items in preceding three licensing years	:

S.No	Year	Name of the item	Licence no. and date	Qty & value in US$ of the licence	Qty & value in US$ of the item exported	Name of the end user	Country to which exported
[1]	[2]	[3]	[4]	[5]	[6]	[7]	[8]

5.	If applied for export on repeat basis in the same licensing year for same product and end-use and to the same end-user, then following information may also be furnished	:
	(i) Reference number and date vide which the earlier permission was granted by this office	:
	(ii) Export licence number and date	:
	(iii) Quantity allowed for export	:
	(iv) Quantity exported on the date of this application	:
6.	Export Order No. & date (Attach copy)	:
7.	Name and full address of the buyer	:
8.	Name and full address of the end user	:
9.	Port of shipment	:
10.	Destination of export	:
	(i) Port of Discharge	:
	(ii) Ultimate Destination	:
11.	End product for which the item of export will be used by the end user (attach end user certificate)	:
12.	The purpose for which the end product will be utilised	:
13.	If application is for export of samples, furnish the following details	:
	(i) Ceiling limit	:
	(ii) How much in excess of the ceiling limit	:
	(iii) Justification for excess	:

PART-III

(To be filled in for export of all other Category items of Appendix-3 except those covered by Part-II above )

14.	Category, item number and item name as in Schedule 2 Appendix 3 of ITC (HS) Classifications of Export And Import items (Attach technical specification not exceeding one page for item, in the order in which these items have been listed)	:
15.	(i) Quantity applied for	:
	(ii) FOB value per unit (US $)	:
	(iii) Total FOB value (US $)	:
16.	Importer"s Purchase Order number and date (Attach copy)	:
17.	Is the applicant the producer/ manufacturer of the item to be exported ? If not, name the producer/ manufacturer and provide full address, telephone No. etc.	:
18.	Details of Export Licences (EL) previously applied for items under Schedule 2 Appendix 3 of ITC(HS) (HS) Classifications of Export and Import items	:

S.No.	Date of application	No. & date of export licence (see Note below)	Items exported & Qty-Value	Date of shipment (attached B/L copy)	Destination Country
[1]	[2]	[3]	[4]	[5]	[6]

* State "denied", if the licence was denied. A false statement will invite prosecution.
19.	Port of Shipment (Delhi, Mumbai, Calcutta or Chennai -Identify only one Port)	:
20.	Destination of Export (Country)	:
21.	Name of the consignee, complete postal address; telephone, fax etc.	:
22.	Citizenship of consignee (if individual)	:
23.	Headquarters address of consignee, if corporate office different from entry at (10) above.	:
24.	(a) Location (country) of end-user	:
	(b) End product and/or end- purpose for which the exported item will be used by the end user. (Attach end-use certificate in the prescribed proforma)	:
	(c) Name and complete address of end-user (include telephone, fax Nos. etc.)	:
	(d) Is end-user an entity of Government of destination country?	:
	(e) Manufacturing/Business/Other activity of the end user.	:
25.	Through which banks will the financial transactions relating to this export be executed?	:
	(a) In destination country (provide full address)	:
	(b) In India	:
26.	Name and address of all foreign Collaborators of the applicant (as registered with GOI/RBI). If none, state None.	:
27.	Period during which the item is proposed to be exported from India.	:
28.	If revalidation required	:
	(a) Period of extension sought	:
	(b) Reasons therefor	:

DECLARATION/ UNDERTAKING

I/We solemnly declare/undertake that:-

(i) The particulars and the statements made in this application and attachments thereto are true to the best of my/our knowledge and belief, and nothing has been concealed or withheld therefrom.

(ii) If any information furnished in this application is found to be false, inaccurate, not current or misleading, any licence granted on the basis of this application shall be liable to cancellation or being made ineffective without prejudice to any other action that may be taken in this behalf under the Foreign Trade (Development and Regulation) Act, 1992, or rules and orders made thereunder, and the Customs Act, 1962.

(iii) Any information furnished in this application if proved incorrect, false, inaccurate, not current or misleading will render me/us liable for any penal action or other consequences as may be prescribed in law or otherwise warranted. (iv) I/We further declare that no export proceeds areOutstanding beyond the prescribed period as laid down by the RBI, or such extended period for which RBI permission has been obtained.

(v) I hereby certify that I am authorised to certify and Sign this declaration as per Paragraph 9.9 of the Policy.

(vi) I/We further undertake to submit to the DGFT (PC-III Section) a copy of the Bill of Entry into the destination State Party within 30 days of delivery failing which I/We shall be liable to action under the Foreign Trade (Development and Regulation) Act 1992, or Rules and Orders made thereunder and the Customs Acts, 1962.

Place:
Date :

Signature of the applicant _________________
Name in block letters _________________
Designation _________________
Official Address _________________
_________________
Residential _________________
Address _________________
E.Mail Address _________________

Note: Each page of this application should be signed individually by the Managing Director, or the Company Secretary or a Director of the firm. If signed by a Director of the firm, then that Director must be duly authorised to do so by the Board of Directors of the firm.

This Certificate is to be furnished by the exporters of Categories 1B & 1C items of Appendix-3

END USE CERTIFICATE

(To be furnished with reference to S. No.11 of this Export Licence Application)

We, (name of the end user), certify that we are importing _________________ M.T. of____________ from (name and address of exporter) for the manufacture of ______________(state specific use)

We further certify that we will not use the above mentioned chemical for any purpose other than stated as above nor transfer or re-export the item to any other party/country for any other purpose.

Place:	Signature of end-user with Stamp and Seal
Date:	Name: Designation:

Note:: The exporter shall furnish a copy of confirmed export order indicating number and date to the customs and DGFT at the time of actual shipment.

This Certificate is to be furnished by the exporters of all other category items (except categories 1B & 1C) of Appendix-3

END USE/END USER CERTIFICATE

[Read instructions at foot of page]

1. I/We _________________________ a/ hereby certify that we are the end-user of _______________________ b/ to be imported from ____________________________ c/ against our Purchase Order No. ______________ dated __________ for the manufacture of/used for __________________________ d/.

OR
The undersigned, hereby declares that I am duly authorised to certify that _______________________ a/ are the end-users of the items detailed in their Purchase Order No. ____________ dated __________ and are importing the said items from ___________________ c/ for the manufacture of/used for ___________________ d/.

2. I/We further certify that the items detailed in the referenced Purchase Order will not be used for any purpose other than the purpose(s) stated in the Purchase Order, and that such use will not be changed nor the items modified or replicated without the prior consent e/ of the Government of India.

3. The end-user shall not himself, or through another, cause the items, or replicas, or derivatives thereof to be re-transferred/sold without the knowledge/consent e/ of the Government of India, to any party within ________________ f/ or outside it.

4. I/We also certify that all the facts contained in this certificate are true and correct to the best of my knowledge and belief and that I/we do not know of any additional facts that are inconsistent with this certificate.

Place:
Date :

____________________________________
Signature of end-user/authorised signatory
of end-user with stamp and seal

Name : _____________________________
Designation : ________________________

Instructions:

a/ Name of end-user as at entry 24(c) of this Export Licence Application.

b/ Items entries as at Sl. No. 14 of this Application.

c/ Name and address of exporter in India.

d/ Name of the end product/end use.

e/ DGFT will state the condition in export licence. Do not strike out.

f/ Destination country.

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