Note: 1. Please read the general instructions given at Appendix 1 before filling this application. 2. In addition to 15 copies of this application form, please also submit Appendix-1A (in duplicate) alongwith this application. ----------------------------------------------------------------- FOR OFFICIAL USE File No. :-------------------------------- Date :------------------ ----------------------------------------------------------------- 1. Name and address of the applicant : 2. (a) IEC Number : (b) PAN Number : 3. Purpose of Export (Trade / : Personal / Sample) 4. Relevant Para of the Policy : under which licence is sought 5. (i) Item of Export : (ii) Quantity applied for : (iii) FOB value per unit : (iv) Total FOB value : 6. If the application is for export of seeds (S.No.19 of paragraph 16.2, give the following additional informations: (i) Details of seed / planting material proposed for export.

S.No	Crop	Variety	Qty. in Kgs Number of pieces	FOB price per unit

(ii) Whether seed / Planting material : proposed to be exported is of notified variety. (iii) Whether seed / planting material : proposed to be exported has been produced under custom production arrangement? If so, enclose details / agreement entered into with buyer (iv) Whether the variety of seed / : planting material proposed to be exported is used in India. (v) Places whether the variety : proposed to be exported is grown. (vi) Any other relevant information. : 7. Details of the exports of the item applied for in preceding three years (give information : in following form)

S. No.	Year	Licence No.& Dt.	Qty. & value in US$ of the Licence	Qty. & value in US$ of the item exported	Destination of export

8. Export order No. & Date : (Attach copy) 9. Name and address of the : buyer 10. Port of shipment : 11. Destination of Export : 12. If application is for export : of samples / exhibits / gifts give the following details: a) Ceiling Limit : b) How much in excess of the : ceiling limit. c) Justification for excess. : 13. If export is by Post, : Post Office where the parcel will be placed. DECLARATION / UNDERTAKING I / we hereby solemnly undertake / declare that:- (i) The particulars and the statements made in this application and annexures attached thereto are true to the best of my / our knowledge and belief and nothing has been concealed or withheld therefrom. (ii) 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, if any information furnished in this application is found to be wrong or incorrect or misleading. (iii) Any information furnished in the above statement, 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. (iv) 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. (v) 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 in Block Letters -------------------- Designation -------------------- Official Address -------------------- Residential Address -------------------- E-Mail Address --------------------