DC NO:

1.Name of EOU:

2.IEC No.(of the EOU):

3.Factory Address:

4.Date of Examination:

5.Name and designation of the examining
Officer-Inspector/EO/PO:

6.Name and designation of the supervision
Officer-Appraiser/Superintendent:

7.(a)Name of Commissionerate/Division/Range:

   (b)Location Code:

8. Particulars of Export Invoice

   (a)Export Invoice No.:

   (b)Total No. of packages:

   (c)Name and address of the consignee abroad:

9.(a) Is the description of the goods,the Quantity and their value as:

   (b)Whether sample is drawn for being forwarded to port of export:

10.(a) For Non-containerized cargo

Nos. of packages

   (b) For Containerized cargo

Name:          ______________________

Name:          ______________________

Name:          ______________________

Designation:______________________

Designation:______________________

Designation:______________________

Stamp:          ______________________

Stamp:          ______________________

Stamp:          ______________________

Note:

1.The office supervising the examination should attest Invoice(s) and any other document accompanying this

2.* To be filled in by the exporter before filling this documnet at the time goods registration in the export shed.

3.* Revised 6 digit code as assigned by the directorate of S & I,XXYYZZ

Commissionerate

Division

Range