1. Shipping Bill No. & Date:-

2. Invoice No. & Date:-         

3. Nature of Transaction

Sale Sale on consignment Basis Gift

Sample Other

4. Method of Valuation
(See Export Valuation Rules)      Rule 3 Rule 4 Rule 5 Rule 6

5. Whether seller and buyer are related      Yes No

6. If yes, whether relationship has influenced the price      Yes No

7. Terms of Payment — Select —Advance Payment (100%)Letter of Credit (at sight)Letter of Credit (30 days)Documents against Payment (D/P)Documents against Acceptance (D/A)30 days from B/L date45 days from B/L date60 days from B/L date90 days from B/L dateOpen AccountTelegraphic Transfer (T/T)Other (type below)…

8. Terms of Delivery — Select —EXWFCAFASFOBCFRCIFCPTCIPDAPDPUDDPOther (type below)…

9. Previous exports of identical/ similar goods, if any — Select —NilNot ApplicableYes (give details below)Other (type below)…

Shipping Bill No. and date:

10. Any other relevant information (Attach separate sheet, if necessary) — Select —NilNot ApplicableSeparate sheet attachedOther (type below)…

DECLARATION

1. I/We hereby declare that the information furnished above is true, complete and correct in every respect.

2. I/We also undertake to bring to the notice of proper officer any particulars which subsequently come to my/our knowledge which will have bearing on a valuation.

Place: — Select place —KOLKATAMUMBAIDELHICHENNAINHAVA SHEVAMUNDRABENGALURUHYDERABADAHMEDABADOther (type below)…

Date:

SIGNATURE OF THE EXPORTER
NAME OF THE SIGNATORY