3240738038370105176116928

FORM 403
(See sub-rule (5) of rule 51)
(For goods entering into the State from outside the State)
Declaration under Section 68 of the Gujarat Value Added Tax Act, 2003

Form No. 172335333

Date: 16-MAY-2017 06:39:49 PM
To,
The officer in charge
Check post BHILAD
(1) Place to which goods are dispatched : Gujarat District : KACHCHH
(2) Place from which goods are dispatched : Maharashtra District : Mumbai
(3) Details of goods :

Sr. No. Invoice No. Invoice Date

1 17182001 17/04/2017
(4) Consignees details :
Name TERRAM GEOSYNTHETICS PRIVATE LIMITED State Gujarat
Address A/704,SAFAL PEGASUS,PRAHLADADNAGAR 100 FOOT Registration No. 24073803837
ROAD,VEJALPUR,AHMEDABAD,AHMEDABAD-380051
Date 15/12/2008 Telephone
CST No. 24573803837 Fax No.
(5) Nature of Transaction : SEZ
(6) Consignors details :
Name Team Logisitcs Registration No. 999999999
Address Mumbai Date
Telephone CST No.
Fax No. Date
Consigned Value Rs.565907
Sr. Description of Goods Commodity Unit Unit Rate of Commodity Invoice No.
No. Code Quantity Measure Tax Value
1 All goods not specified elsewhere 99109000 1000 Kgs 0 565907 17182001
(7) Transporters Details :
(a) Name : Agrawal Logistics
(8) Vehicle No : i) MH02CE6462 ii) L.R.No. : Date :
(9) Drivers Details:
(a) Name : (b) Driving License No. : (c) License issuing State :
(d) Drivers Signature : (e) Address :
(10) Name and the address of person in charge of goods __________________________
Seal :
Place: ____________________Date: ____________________Designation: _______________________Signature: _______________________

For Commercial Tax Department/Check post

Entry No. Reason of Result if any Vehicle
Abnormal
stoppage
Date Time Arrival
Depart
Date: ________________ Designation: _________________ Status: _________________