Government of Madhya Pradesh

Form No:

Commercial Tax Department

Signature Not Verified
Digitally signed by SALVI RAKESH KUMAR Date: 2012.04.05 19:07:53 IST

Shajapur Circle

Form 49
[See rule 70(3)] DECLARATION
Date/Time of Issue: 05 April 2012 7:7 PM

Details of the dealer whom issued Name Address Door No./Shop No. Village District Phone No The Consignor Name of the other state: KALAPIPAL M/S MATHURA SAMRUDDHI SALES KALAPIPAL BUS STAND - KALAPIPAL TIN Street/Complex Town City Ward No Mobile No 23482506133

Samruddhi Industries Limited

Address I.I.E. Pantnagar Sector-6 Plot No.24&25 Rudrapur Dist.-U S Nagar Uttarakhand

Place from which the goods dispatched: Place Rudrapur

Name

Address

Bilty/LR No.

Da

te ue Iss
Date Designation

Bilty/LR Date

I, ____________________declare that to the best of my knowledge and belief the above statements are true and correct. Place: Date: Seal and signature of the consignor of the goods

To be completed in the office of the checkpost: Date and time of arrival of the vehicle at the check post: Date and time of departure of the vehicle from the check post: Reasons for abnormal detention of the vehicle at the check post:

Seal

7:7

:0

Carrier (transport company or owner of the vehicle etc):

Vehicle Number

PM il 2 01 2
Signature

Please take the print of overleaf details of this form on the backside of main page. PLEASE DO NOT TAKE THE PRINT OF OVERLEAF DETAILS ON SEPARATE SHEET.

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Form No: Overleaf details of form 49: Sr.No Consignor's Invoice No Consignor's Invoice Date Destination Place(including complete address) Brief description of goods Total Quantity/Total weight Units Other Description Total Value

Place: Date:

Iss

ue

Da

te

7:7
Seal and signature of the consignor of the goods

:0

PM il 2 01 2

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