1.  Name &  address of the licensee    	: ...............................
					  ...............................

2.  IEC No                            		: ...............................

3.  (a) Licence No. & Date               		:................................

     (b) CIF value                        		:................................

     (c) File No. from which the licence .	: ..............................
          was issued


4.       	Details of licence                        		Utilisation of licence


S.No.
Item
Quantity
Value
In % quantity terms
In % value 

terms
 
(1)
(2)
(3)
(4)
(5)
a.

b.

c.
 
 
 
&nbs

p;
 
 
 
 
Total: ___________	

 

5. Details of EO fulfillment:



Export obligation
Export obligation completed (During initial period ...........)
S.No.
Item
Value
Quantity
Value terms 

(Rs./%)
 	Quantity terms (%)
 
(1)
(2)
(3)
 (4)
(5)
a.

b.

c.
 
 
 
&nbs

p;
 
 
 
 
 
Total: 

___________	



Export Obligation Completed (During extended period.......)
Unfulfilled  Export 

Obligation
(6)
(7)
(8)
(9)
Value term(Rs./%)
Quantity term(%)
Value term(Rs./%)
Quantity 

term
 
 
 
 

6   Extension in Export obligation   		: ...............................
     period applied upto

7.  Validity of Licence:


Initial validity
Extended validity
Revalidation 

appliedupto
(1)
(2)
(3)
 
 
 



8. Bank Receipt/Demand Draft No 	   	:  ...................................
    Date:           			   	:  ...................................
    Value:          			   	:  ...................................
    Issuing Bank-   			   	:  ...................................
    Branch

9. Reasons for seeking revalidation/       	..................................
    extension in export obligation period:

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 9.9 of the 
	Policy.


	Place :         	 			 Signature of the Applicant:..............

	Date : .................
	Name : .................

						Designation	:.....................
						Official Address	:.....................
						Tele.No		:.....................
						Residential Address	:.....................
						E.Mail Address	:.....................


Documents to be enclosed with the application form


1.	Bank Receipt (in duplicate)/Demand Draft evidencing payment of application fee in terms of Appendix-29
	as applicable.

2.	Import Licence in original and a self certified copy thereof.