ANF 5D
(
For Clubbing of EPCG Authorisations)
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1. IEC Details
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i. IEC Number
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ii. Date of Issue
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iii. Issuing Authority
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2. Applicant
Details
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i. Name
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ii. Address
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1. Details of EPCG Authorisations to be clubbed
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S
No
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EPCG Authorisation No
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EPCG Authorisation date
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Customs Notification no
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Export product/Services
to be rendered
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Port of Registration
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1
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2
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3
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4
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5
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6
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CIF value /duty saved permitted (Rs)
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CIF value/ duty saved
utilized (Rs)
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Customs duty saved (Rs)
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EO endorsed on the Authorisation
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EO wrt imports made
(US $)
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Exports made/Services
rendered
( US $)
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7
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8
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9
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10
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11
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12
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2. Details of single clubbed EPCG Authorisation
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i. Total Duty Saved or CIF Value on the imports/deemed imports
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a. In Indian Rupees
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b. In free foreign exchange
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ii. Export Obligation imposed on the Authorisation
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a. In Indian Rupees
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b. In free foreign exchange
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iii. Average Export Obligation imposed (Rs)
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iv. Export Product/Service to be rendered
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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
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
Office(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 authorised to verify and sign
this declaration as per Paragraph 9.9 of the Policy.
Signature of the
Applicant Place
Name
Date
Designation
Official Address
Telephone
Residential Address
Email Address
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