APPENDIX - 3 A

------------------------------FORM OF APPLICATION FOR REGISTRATION CUM MEMBERSHIP WITH

EXPORT PROMOTION COUNCILS
-------------------------------------------------------------------NOTE: Please see paragraph 13.8 of the Policy and paragraph 13.3
of this Handbook
-------------------------------------------------------------------FOR OFFICIAL USE
File No.:-------------------------------- Date:---------------------------------------------------------------------------------------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.

Address of the
applicant
(Registered
Office
in
case of limited companies,
and
the head
office
for others )

:..............................
:...............................

2A.

Name address of the branches,

if any

2B.

Name and address of the factory

__________________________
__________________________
--------------------------

3.

IEC No. ...........Date of Issue ....... Issuing Authority ......

3A.

PAN No.........................

App.13

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/Golden status ................. Valid upto...........

Certificate no.

5(a)

SEH/ISEH/ISSEH/ISSEH
Certificate No.

6.

Details of Directors/Partners/Proprietor/Karta to be given

in the following manner
(1)

(2)

(4)

7.

8.

...............

(a)
(b)
(c)

Name
Father's Name
Residential address

(d)

Telephone No.

(a)
(b)
(c)

Valid upto ..........

_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
(a)
(b)
(c)

(d)

______________________(3)
______________________
______________________
______________________
______________________
______________________

(d)

_____________________
_____________________
_____________________
_____________________
_____________________
_____________________

(a)
(b)
(c)
(d)

______________________(5)
______________________
______________________
______________________

(a)
(b)
(c)
(d)

_____________________
_____________________
_____________________
_____________________

Name of export product(s) for which

registration is required.

__________________________

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;

App.14

(d)

9.

furnish without fail monthly returns of exports

including
nil
returns to
the
Registering
authority by 15th day of the months following the
quarter.

We further understand that our registration is liable to

be cancelled 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

_______________

---------------------------------------------------------------------Documents to be enclosed with the application form:

---------------------------------------------------------------------1.
A self certified copy
licensing authority concerned.

of

the

IEC

Number

issued

by

the

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

App.15