APPENDIX 19A

FORM OF APPLICATION FOR REGISTRATION CUM MEMBERSHIP (RCMC)
WITH EXPORT PROMOTION COUNCILS

To,

The _______________________________

___________________________________

___________________________________

(Name and Address of the Council)

Dear Sir,

Kindly register us as Merchant/Manufacturer exporter of the export product(s) mentioned below.

1.	Name of the applicant	: ______________________________
2.	(i) Address of the applicant. (Registered Office in case of limited companies, and the head office for others)	: _______________________________ ______________________________ _______________________
	(ii) Name address of the branches, if any	: _________________________________ __________________________________ _________________
	(iii) Name and address of the factory.	: _______________________________ __________________________
3.	(i) IEC number Date of issue Issuing authority	: ______________________________ _____________________________________ _________________
	(ii) Date of establishment	: ______________________________ ________________________________ ______________________
4	If the registration is required as a manufacturer exporter SSI Registration Industrial Licence/IEM	: No. ________________________ Date _______________________ Issuing Authority: _____________ ___________________________
	Others (specify)	: ___________________________
5.	EH/TH/STH/SSTH/SHE/ISEH/ISSEH/ISSEH certificate number	: Valid upto __________________
6.	Details of Directors/Partners/Proprietor/Karta to be given in the following manner
	(1) (a) Name	: ____________________________
	(b) Father"s Name	: ____________________________
	(c) Residential address	: ____________________________ ____________________________ ____________________________
	(d) Telephone No.	:
	(2) (a) _____________________ (b) _____________________ (c) _____________________ (d) _____________________	(3) (a) _______________________ (b) ________________________ (c) ________________________ (d) ________________________
	(4) (a) _____________________ (b) _____________________ (c) _____________________ (d) _____________________	(4) (a) ________________________ (b) ________________________ (c) ________________________ (d) ________________________
7.	(a) Name of export product(s) or its category for which registration is required	: ____________________________
	(b) Main line of business of applicant	:
8.	I/We hereby solemnly declare that the above stated information is true and correct. I/We undertake, without any reservation, to: (a) abide by the terms of the registration certificate granted to us on all our exports; (b) agree to abide by any code of conduct that may be prescribed; (c) agree to abide by export floor price condition that may be stipulated by the Registering Authority; (d) Furnish without fail monthly returns of exports including NIL returns to the Registering authority by 15th day of the months following the quarter.
9.	We further understand that our registration is liable to be cancelled in the event of breach of any of the undertakings mentioned above.
10.	We/ I solemnly declare that we have applied to the Export Promotion Council which pertains to our main line of business. In case we have applied to any other council, the application has been made within the purview of the provisions of para 3.12 and 3.12.1 of the Handbook of Procedures (Vol 1).

Name Address Designation Tele No: Fax No: E.Mail Address: Residential address

Yours faithfully, (Signature) ___________________________. ___________________________. ___________________________. ___________________________. ___________________________. ___________________________. ___________________________. ___________________________. ___________________________. ___________________________.

Place _______________
Date _______________

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Documents to be enclosed with the application form:

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1. A self certified copy of the IEC Number issued by the licensing authority concerned.