1. Please see paragraph 7.4 of the Policy and Paragraph 7.55 to 7.62 of this Handbook. 2. Please read the general instructions given at Appendix-1 before filling this application. 3. Please submit 2 copies of this application. -------------------------------------------------------------------------------------- FOR OFFICIAL USE File Number:----------------------------------------------- Date:-------------------- -------------------------------------------------------------------------------------- 1. Name and address of the applicant :................................. 2. I.E. Code No.: : ....................................... 3 PAN Number : : ....................................... 4. Export Product Group: : ....................................... 5. Sr.No. of Standard Input-Output Norms: 6. Total FOB value Rs......... In currency .... in US$ ....... realised of exports 7. Total CIF value of Rs. ........ in currency .... in US $ ...... imports: of exports 8. Value addition: 9. Application fee a) Bank Receipt/ :............................ Demand Draft No.and ............................. date b) Rupees: ............................. ............................. c)Issued by : : ............................. 10. Port of Export : ...................................................... 11. Details of the product exported (Resultant Products).

S.No	Resultant Product		Total quantity	Unit of measurment		FOB value
	NameTecnical Characteristics and quality	ITC(HS) Code		Name	Code	In rupees	In freely convertible currency(FCC)

12. Details of Items sought to be Imported Duty free as replenishment.

S. No.	Import Item		Total Quantity	Unit of measurement
	Name, Technical characteristics and quality	ITC(HS) Code		Name	Code

Per unit CIF value			Total CIF value			Toal exemption from Customs duty
In rupees	In free foreign exchange		In rupees	In free foreign exchange		Basic Customs Duty	Surcharge	Special Additional Duty
	In Rs	US$		In Rs	US$

13. Details of other materials used in resultant product and imported/ procured from sources other than the licence.

S.No	Resultant Product(s) (Name Technical characteristics and quality)	Total Quantity	Import Items			Indigenously procured item
			Name Technical Characteristics and Quality	Quantity and unit of measurement	CIF Value	Name Technical Characteristics and Quality	Quantity and unit of measurement	Value

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/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. 5. I hereby certify that I am authorised to verify and sign this declaration as per Paragraph 3.8 of the Policy. 6. I/We hereby declare that the international prices of inputs and CIF value as given in S.No.7 of the application form is true and correct. (The above declaration has been amended vide Public Notice No.6(RE-2000) / 1997-2002 dt.7-4-2000) Place : Signature of the Applicant: ....................... Date : Name: ...................... Designation: ........................ Official ddress:......................... ........................ Tele No:.......................... E-MailAddress......................... -------------------------------------------------------------------------------------- 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. EP copy of the Shipping Bill. 3. Bank Certificate of Export and Realisation as given in Appendix-25. 4. A statement of exports giving separately each Shipping Bill number and date, FOB value in Indian rupees as per Shipping Bill and description of the resultant product