1. IEC Number:

 3.ApplicantFeeDetails:

i.         Amount in Rupees

ii.        Demand Draft/Bank Receipt/ Electronic Fund Transfer Number

iii.       Date of issue/Transfer

v.       Name of Bank on which drawn

v.       Bank Branch on which drawn

 4. Jurisdictional Regional Authority:

 5. Detail of activities and operations:

6. Details of the provisions of the arrangement or understanding involving site visits / on-site verification access to records / documentation (e.g. nature of documentation, mode of verification, nature and frequency of site visits etc.) Please include all details and attached draft of relevant declaration/arrangement/ MOU etc.*

 8. In case purpose is export/import of SCOMET Items, following details may be provided:

 (a). Details of SCOMET items in Appendix 3 of Schedule 2 of ITC(HS) Classification of Export & Import Items:

Sl. No.

Description of export /import items
including technical specification

SCOMET Category
i.e. 1B, 1C,2,3,4,5 and7

SCOMET Item N o.

ITC (HS) Code No.
(if available)

Quantity

(b) End user Details:

i.         Name

ii.        Address

iii.       Telephone No.                           iv. Fax No.

v.        Location(Country)of end user

v.        End product for which the item of export will be used by the end user

vi.       Purpose for which the end product will be utilized

vii.      Is end user an entity of Government of destination country?

viii.     Manufacturing/Business/other activity of the end user

 9. Details of export/ import of SCOMET items in the preceding 3 licensing years:

Sl. No.

Export/Import Licence /Authorization Details

Category &Descriptio n of items Exported /Imported

Qty. exported /imported

 Date
 Of
 Ship
 ment

FOB Value of Exports /Imports(U S $)

Country to/from which exported /imported

Name of the End User

No.

Date

Qty

Value (US$)

 10.Details of the Foreign Government/ Foreign Third Party**

   1. Name

   2. Address

   3. Telephone No.

   4. Fax No.

   5. Is the party, an entity of Govt. of that country?

 11. If the visit/verification/access to records will be through an Indian Party, details of the Indian Party:

 i. Name

 ii. Address

 iii. Telephone No.                                     iv. Fax No.

 iv. Address of Corporate Office.

 13. Detail of sites and activities which will be covered by the arrangement/ understanding

 (I)

 i.        Address

 ii.       Telephone No.

 iii.       Fax No.

 iv.       Nature of Unit: Corporate Office/Registered Office/Branch Office/Manufacturing unit/Laboratory.

v.         Activity

 (II)

     i.    Address
     ii    Telephone No.
     iii.   Fax No.
     iv.  Nature of Unit: Corporate Office/Registered Office/Branch Office/Manufacturing unit/Laboratory.
     v.   Activity

 14. Details of persons /individuals who shall visit during site visit/on-site verification etc.

 (I)

 i.      Name

 ii.     Address

 iii.    Nationality

 iii.    Position/Designation in the foreign government/ Foreign third party / Indian Party

 iv.    Telephone No.                                    v. Fax No.

 (II)

 i.      Name

 ii.     Address

 iii.    Nationality

 iv.    Position/ Designation in the foreign government/ foreign third party /Indian Party

 v.    Telephone No.                                     vi. Fax No.

#Enclose additional sheet, if required.

 15. If applied for permission for entering into arrangement / understanding that involves site visit, on- site verification or access to records/documentation on repeat basis during last five(5) licensing years for the same purpose, please furnish:

 Reference Number and date vide which earlier permission granted

 16. Foreign Collaborator Details (As registered with GOI/RBI) (If No
 foreign collaboration exists, please None’)

       i.      Name

       ii.     Address

1

I/We hereby certify that:

         A. The entity for whom the application has been made have not been penalized under any of the following Acts (as amended from time to time):
               a.TheCustomsAct,1962,
               b.TheCentralExciseAct1944,
               c. Foreign Trade (Development & RegulationAct1992,and
               d.TheForeignExchangeManagementAct,1999;
               e. TheConservationofForeignExchange,PreventionofSmugglingActivitiesAct,1974
               f. WeaponsofMassDestruction&their Delivery Systems (ProhibitionofUnlawfulActivities)   Act,2005

              B. none of the Directors / Partners /Proprietor / Karta
             Trustees of the company /firm /HUF/Trust, (as the case may
             be), is/are a Director(s) / Partner(s) / Proprietor / Karta /
             Trustee in any other Company/firm/entity which i s on the
             Denied Entity List (DEL) of DGFT or in the caution list of RBI;

            C. Neither the Registered
            Office of the company / Head Office of the firm / nor any of its
            BranchOffice(s)/Unit(s)/Division(s)hasbeendeclaredadefault
            erandhasotherwisebeenmadeineligiblefor undertaking
            import /export under any of the provisions of the Policy;

           D. We have not obtained nor applied for issuance of an
           Importer Exporter Code Number in the name of
           Our Registered /Head Office to any other Licensing
           Authority

2

I/We undertake to abide by the provisions of the Foreign Trade (Development and Regulation) Act,1992, as amended, the

Rules and Orders framed there under, the Foreign Trade Policy, the Handbook of Procedures and the ITC (HS) Classification of Export & Import Items.

3

I/We fully understand that if any information furnished in the application is 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.

4

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 withheld the refrom.

5

I/We hereby declare that I /We have not obtained nor applied for such benefits (including issuance of an Importer Exporter Code Number)in the name of our Registered /Head Office or any of our Branch(s)/Unit(s)/Division(s)to any other Regional Authority.

6

I/ We solemnly declare that I / We have applied or / obtained a RCMC to the EPC which pertains to our main line of business .In case we have applied to any other council, the application has been made within the purview of the provisions of Para 2.94 of the HBP.

7

(i) I/We further undertake to maintain record of the site visit, on-site verification or access torecords/documentationandproducethesameasandwhenaskedtodosobytheGovernmentofIndia.

(ii) I/We also hereby inform that we have complied with the conditions of all previous permissions issued to us for entering into an arrangement or understanding that involves site visit, on-site verification or access to records/documentation.

8

I hereby certify that I am authorized to verify and sign this declaration as per Paragraph 9.6 of the Foreign Trade Policy.

Place:

Signature of the Applicant

 Name

 Designation

Date:

 Official Address

 Telephone

 E-mail Address