...................................................................................... 1. Please see paragraph 6.6 of this Handbook. 2. Please read the general instrutions given at Appendix 1 before filling this application. 3. Please submit 15 copies of this application form, .................................................................................... FOR OFFICIAL USE File No.:.............................. Date:.......................... ................................................................................... 1. I.E.C Number : ....................... 1(a) PAN Number : ....................... 2. Name and address of the applicant : ....................... (Domestic manufacturer of CG) ....................... 3. Address of the factory where the : ....................... components imported under this ....................... scheme will be assembled. ....................... 4. Manufacturer Details : ....................... Type of unit : ........... Reg. Number :....... Date:......... 5. Details of ultimate EPCG (i)Name and address :............. licence holder .............. (ii)EPCG Lic. No. :............. and date :............. (iii)Value of Lic. :............ 6. Whether BG / LUT executed by EPCG : ....................... Licence holder 7. Details of Contract(between EPCG : Reference No.......Dated..... Licence holder and supplier) : ....................... Reference No. and Date : ....................... 8. Details of the CG contracted for :....................... supply by the applicant to the EPCG Licence holder -------------------------------------------------------------------------------------- S.No. Description of Qty. Value Delivery Schedule Capital Goods -------------------------------------------------------------------------------------- (1) (2) (3) (4) (5) -------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------- 9. Details of the Components sought to be imported under this scheme :.................................. -------------------------------------------------------------------------------------- S.No. Item Description Quantity Value Country of Import. -------------------------------------------------------------------------------------- (1) (2) (3) (4) (5) -------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------- 10. Application fee Rs........ Bank Receipt / DD No........... Date........ Issued by .................................. 11. Justification about the quantity of :......................... components / raw materials required .......................... for import in relation to the Capital .......................... Goods to be manufactured for supply .......................... to the EPCG licence holder DECLARATION / UNDERTAKING I / We hereby solemnly undertake / declare that:- (i) 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. (ii) I / We full 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. (iii) 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. (iv) That I / We shall be liable to penal action in accordance with the Policy / Procedure / Foreign Trade (Development & Regulation) Act, 1992 the Rules and Orders framed thereunder and the Customs Act,1962 addition to forfeiture of Bank Guarantee or any other Bond / Guarantee given to the Customs, in the event of failure to supply the contracted capital goods to EPCG licence holder. (v) I / We further declare that no export proceeds are outstanding beyond the prescribed period as laid down by the RBI ,or such extended period forwhich RBI permission has been obtained. (vi) I hereby certify that I am authorised to verify and sign this declaration as per Paragraph 3.8 of the Policy. Signature of the Applicant:............ Name: ................ Designation: ................ Official Address: ................ ................ Tele.No.: Place : Residential Address: ................ Date : ................ 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-34. 2. Self certified Copy of the Proforma invoice / quotations of the foreign supplier showing separately (i) the amount on quotations of freight and (ii) insurance included in the CIF value quoted. In case the Proforma invoice is on FOB basis, the applicant shall indicate the freight and insurance separately in the application form. 3. Manufacturers illustrated pamphlets / catalogue. 4. Self certified copy of the contract between the indigenous manufacturer of Capital Goods (applicant) and the EPCG licence holder indicating the value, Quantity and description of Capital Goods as indicated on the EPCG licence and sought to be sourced from the indigenous manufacturer.