Job No:

FORM 'N'

00077/S/RSR/07-08

MUMBAI, 19/02/2008

To,

Import-Export

The Dy. ASSESSOR & COLLECTOR (OCTROI)

Free Of Octroi

Sir,
We have to request that the undermentioned Articles which have been imported by me per
from

No.

and landed at

from place of export

Date

for the purpose of immediate exportatio

per

and to be consigned to (name of consignee)

at (destination)

be exempted

Initials Of
Registering Officer

from the levy of octroi.

Number and
Number
date of Import
of Pkgs
document

Description of
Packages

Description of Articles

Import Marks If Any

Weight or
Quantity as per
Import Document

Number of Packages
escorted earlier
N Form No.

Let the above articles be removed free of Octroi to the place of export

No Pkg

Number of Packages on
which octroi has been Number Of Number and
Pkgs To
Date Of
Weight and value
paid
Be
Export
and rate for Octroi
Escorted Document
No Pkg
Imp Bill

Remarks

I/We do hereby declare that the contents of the

under supervision of Shri

Application are truly stated.

(Name and designation)

Signature of the Supervising inspector

Date
(N.B. Please turn over for the reverse side of the form)

Authorised Signatory
(Importer or his Agent or his duly constituted attorney)