FOR OFFICAL USE File No. ................. . Date ............. ------------------------------------------------------------------------------------- 1. Category under which refund of application fee is being claimed: (Please tick) i) Deposited in excess of the specified scale ....... ii) Deposited in error but the applicant is ....... exempt from payment of fee iii) Deposited but no application has been made ....... 2. In case the refund is claimed under category 1 (i) above the following details may be furnished: i) File No:............................................. ii) Licence No. and date in............................................ case the same has been issued : iii)CIF value of the licence applied for :Rs............. iv) Scale of the fee prescribed :......................... v) Fee payable at the prescribed scale : Rs................ vi) Fee paid :Rs............................................ vii) Excess fee paid for which refund is claimed Rs........... 3. In case the refund is claimed under category 1 (ii) above, the following details be furnished: i) File No: ............................................. ii) Licence No. and date in ............................................... case the same has been issued: iii) CIF value of the licence applied for :Rs............. iv) Provision under which the exemption is being claimed: (Please, specify only one of the five category as given in clause 5 (3) of Foreign Trade (Regulation) Rules, 1992) ....................................................................... 4. In case the refund is claimed under ................................ the category 1 (iii) above, the ............... reasons for not making an application after depositing the fee: 5. i) No. and date of the Bank .................................. Receipt / Demand Draft by which .................................. the application fee has been deposited ii) Name and Address of the Bank .................................. where the said fee was deposited ........................ 6. Licensing Authority with whom the .................................. application has been filed / was .................................. proposed to be filed: 7. i) Has this application been filed .................................. within one year of the deposit of ............................... the fee: ii) If not, the detail reasons ................................ thereof: DECLARATION / 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 therefrom. 2. I / We fully 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. 3. 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. 4. 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: ................. Designation: ................. Official Address: ................. ................. Tele.No.: Residential Address: ................. ................. E. Mail address : ................ -------------------------------------------------------------------------------------- Documents to be enclosed with the application form: -------------------------------------------------------------------------------------- 1. Exporter"s copy of the Bank Receipt against which the refund is being claimed.