ANF 5D

(For Clubbing of EPCG Authorisations)

1. IEC Details

i. IEC Number

ii. Date of Issue

iii. Issuing Authority

2. Applicant Details

i. Name

ii. Address

1. Details of EPCG Authorisations to be clubbed

S. No.	EPCG Authorisation No.	EPCG Authorisation date	Customs Notification no.	Export product/services to be rendered	Port of Registration
1	2	3	4	5	6

CIF value/ duty saved permitted (Rs)	CIF value/ duty saved utilized (Rs)	Customs duty saved (Rs)	EO endorsed on the Authorisation	EO wrt imports made (US $)	Exports made/Services rendered (US $)
7	8	9	10	11	12

2. Details of single clubbed EPCG Authorisation
i. Total duty Saved or CIF value on the imports/deemed imports
a. In Indian Rupees
b. In free foreign exchange
ii. Export Obligation imposed on the Authorisation
a. In Indian Rupees
b. In free foreign exchange
iii. Average Export Obligation imposed (Rs)
iv. Export Product/Service to be rendered

DECLATATION / 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 there from if found incorrect or false will render me/us liable for any penal action or other consequences as may be prescribed in law or otherwise warranted.

2. I/We hereby certify that none of the Proprietor /Partner(s)/ Director(s)/ Karta/Trustee of the firm/company, as the case may be, is /are a Proprietor/Partner(s)/ Director(s)/Karta/Trustee in any other firm/Company which has come to the adverse notice of DGFT.

3. I/We hereby certify that neither the Registered Office/Head Office of the firm /Company nor any of its Branch Offices(s)/Unit(s)/Division(s) has been declared a defaulter and has otherwise been made ineligible for undertaking import/export under any of the provisions of the Policy.

4. I/We hereby declare that I/We have perused the list of SCOMET items as contained in the Appendix 3 to the Schedule 2 of the ITC (HS) Classifications of Export-Import items,2004-09 and that the item(s) exported/proposed to be exported does not fall within this list and that I/We agree to abide by the provisions of the Policy for export of SCOMET items contained in the Foreign Trade Policy, Schedule 2 of ITC(HS) and the Handbook of Procedures (Vol.1), irrespective of the scheme under which the item is exported /proposed to be exported ( the underlined portion will be deleted in case an application for export license for SCOMET item is being filed).

5. I hereby certify that I am authorized to verify and sign this declaration as per Paragraph 9.9 of the Policy.

Signature of the Applicant Name Designation Official Address Telephone Residential Address Email Address

Place Date

GUIDELINES FOR APPLICANTS

1. Two copies of the application must be submitted unless otherwise mentioned.

2. Each individual page of the application has to be signed by the applicant.

3. Application must be accompanied by EPCG Authorisation(s) in original.