Central Excise Form
Serial Number______/___-___ (Financial Year).
Certificate for procurement of excisable goods for export without
payment of duty
This is to certify that,
(1) The exporter has furnished a Bond in Form [Specific/General]* for Rs___________________, which has been accepted by the Assistant Commissioner of Central Excise/the Deputy Commissioner of Central Excise in F.No. _______________________ on the _________day of the ___________(month) ___________ (Year).
Mr./Messers. ______________________________(Name and address) is/are registered under rule 9 of Central Excise (No.2) Rules, 2001 in this Range, having registration number__________________________________has furnished an undertaking in the form specified under Notification No. /2001-Central Excise (N.T.) dated----------------------- to the Assistant Commissioner of Central Excise/the Deputy Commissioner of Central Excise, _____________________(Name of the Division or the Office) who has accepted the undertaking in F.No._______________________ on the _________day of the ___________(month) ___________ (Year).
(2) The above-said exporter/manufacturer-exporter is permitted to obtain excisable goods for export under rule 19 of the Central Excise (No.2) Rules, 2001 as per details specified overleaf. This certificate is valid upto one year from the date of issue specified below.
Name and Signature of the
Superintendent of Central Excise
(Address of the RangeOffice)
(To be printed overleaf)
To be filled by the exporter
For Procuring Goods under the procedure specified under
Notification No. 42/2001-Central Excise (N.T.) dated 26th June, 2001
issued rule 19 of the Central Excise (No.2) Rules, 2001
Name and address of the factory/ ___________________________________
warehouse/place of storage of the supplier ___________________________________
Registration Number of the factory/warehouse _________________________________
Details of the goods to be procured
I hereby declare that I have made a provisional debit of Rupees ............................................. (in both words and figures) in the Bond Account at serial No .................................. dated and on this day and after the abovementioned debit, the balance in the Bond Account is Rs. ... .
Please find attested copy of the specific bond/Undertaking details of which is specified by the Superintendent of Central Excise,_____________________________ (address) overleaf.
( Dated signature of the Exporter(s)
or his/ their authorised agents
and their seal.