APPENDIX - 4

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FORM OF APPLICATION FOR REGISTRATION CUM MEMBERSHIP WITH EXPORT PROMOTION COUNCILS

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Note:

Please see paragraph 2.44 of the Policy and paragraph 3.12.2 of this Handbook

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FOR OFFICIAL USE

File No:-------------------------------------------------- Date:----------------------------
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To,

The

_______________________________
_______________________________
_______________________________
(Name and Address of the Council)

Dear Sir,

Kindly register us as Merchant/Manufacturer exporter of the export product(s) mentioned below.

1.	Name of the applicant		:	_______________________
2.	(i)	Address of the applicant. (Registered Office in case of limited companies, and the head office for others)	:	_________________________ ____________________________ _________________________
	(ii)	Name address of the branches, if any	:	_____________________________ _________________________ ______________________________
	(iii)	Name and address of the factory.	:	___________________________ _____________________
3.	IEC No. _______________ Date of Issue _____ Issuing Authority ______
4.	If the registration is required as a manufacturer exporter SSI Registration Industrial Licence/IEM		:	No. ________________________ Date _______________________ Issuing Authority: __________________ ___________________
	Others (specify)		:	_______________________
5.	EH/TH/STH/SSTH/SHE/ISEH/ISSEH/ISSEH certificate number		:	Valid upto ______________
6.	Details of Directors/Partners/Proprietor/Karta to be given in the following manner
	(1)	(a) Name	:	____________________________
		(b) Father"s Name	:	____________________________
		(c) Residential address	:	________________________ ________________________ _________________________ _____________________
		(d) Telephone No	:	___________________________
	(2)	(a) _____________________ (b) _____________________ (c) _____________________ (d) _____________________	(3)	(a) ________________________ (b) ________________________ (c) ________________________ (d) ________________________
	(4)	(a) _____________________ (b) _____________________ (c) _____________________ (d) _____________________	(4)	(a) ________________________ (b) ________________________ (c) ________________________ (d) ________________________
7.	Name of export product(s) for which registration is required.		:	____________________________
8.	I/We hereby solemnly declare that the above stated information is true and correct. I/We undertake, without any reservation, to:
	(a) abide by the terms of the registration certificate granted to us on all our exports; (b) agree to abide by any code of conduct that may be prescribed; (c) agree to abide by export floor price condition that may be stipulated by the Registering Authority; (d) Furnish without fail monthly returns of exports including NIL returns to the Registering authority by 15th day of the months following the quarter.
9.	We further understand that our registration is liable to be canceled in the event of breach of any of the undertakings mentioned above.

Yours faithfully,
(Signature)

Name	___________________________.
Address	___________________________.
Designation	___________________________.
Tele No:	___________________________.
Fax No:	___________________________.
E.Mail Address:	___________________________.
Residential address:	___________________________. ___________________________. ___________________________. ___________________________.
Place _______________ Date _______________

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Documents to be enclosed with the application form:

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1. A self certified copy of the IEC Number issued by the licensing authority concerned.

2. A certificate from the bank in support of the applicant"s financial soundness.

(Expression “paragraph 2.55” appearing in the note to Appendix 4 corrected as “paragraph 3.12.2” vide PN. No. 12(RE-02), Dt. 2/5/2002)