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7/22/2016

FORMXXXVIII

DepartmentofCommercialTaxes,GovernmentofUttarPradesh
[Seerule54oftheUPVATRules,2008]
FormofDeclarationforimport

OriginalCopy

Form38SerialNo
DateofIssue
AssessmentOffice
TIN
NameofDealer
AddressofDealer
1.DescriptionofGoods
2.Weight/Measure
3.Quantity

1607ES28926900413622
22/07/2016
ShamliSector2,AC
09773201398

ThiseSancharanNumberisvalidupto25/07/2016

Date(w.e.f)
M/SA.M.LIFECARE
NOKUHWAROAD,SHAMLI
Medicines
180.00Kilograms
7Box

11/11/2007

4.ValueinFigure
5.ValueinWords
6.Bill/cashmemo/challan/taxinvoicenumber&date

26996.00
RupeesTwentySixThousandNineHundredNinetySixOnly
(AB0296,22/07/2016)

7.GoodsDestinationPlace
8.NameandAddressofseller/consignor
9.TINofseller/consignor

SHAMLI
AMBLEBIOTECHKAITHALHARYANA
06742111723

I,,theauthorizedsignatoryoftheabovenameddealerdohereby
declarethatthegoodsnotedabovearebeingimported/received/broughtbytheaforesaiddealer.

ThisVishishtaSancharanNumber/FormXXXVIIIisonlinegeneratedandassuchdoesnotrequireanysignatureof
importer/seller.

Signatureofauthorizedsignatory
1.Name&addressoftheTransporter/carrieretc.
2.ServiceProviderno.ofthecarrier,ifany

shivalika

3.Carrier/Truckno.
4.Name&addressofDriver
5.DrivingLicenseNo.
6.Signatureofthevehicledriver.

.....

DemandNo:D1607800369065(160700509730) Single(Original)

PrintedOn:22/07/201611:49:14

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7/22/2016

FORMXXXVIII

DepartmentofCommercialTaxes,GovernmentofUttarPradesh
[Seerule54oftheUPVATRules,2008]
FormofDeclarationforimport

SecondCopy

Form38SerialNo

1607ES28926900413622

DateofIssue
AssessmentOffice

22/07/2016
ShamliSector2,AC

TIN

09773201398

ThiseSancharanNumberisvalidupto25/07/2016

Date(w.e.f)

11/11/2007

NameofDealer
AddressofDealer

M/SA.M.LIFECARE
NOKUHWAROAD,SHAMLI

1.DescriptionofGoods

Medicines

2.Weight/Measure

180.00Kilograms

3.Quantity
4.ValueinFigure
5.ValueinWords

7Box
26996.00
RupeesTwentySixThousandNineHundredNinetySixOnly

6.Bill/cashmemo/challan/taxinvoicenumber&date
7.GoodsDestinationPlace
8.NameandAddressofseller/consignor

(AB0296,22/07/2016)
SHAMLI
AMBLEBIOTECHKAITHALHARYANA

9.TINofseller/consignor

06742111723

I,,theauthorizedsignatoryoftheabovenameddealerdohereby
declarethatthegoodsnotedabovearebeingimported/received/broughtbytheaforesaiddealer.

ThisVishishtaSancharanNumber/FormXXXVIIIisonlinegeneratedandassuchdoesnotrequireanysignatureof
importer/seller.

Signatureofauthorizedsignatory
1.Name&addressoftheTransporter/carrieretc.
2.ServiceProviderno.ofthecarrier,ifany
3.Carrier/Truckno.

shivalika
.....

4.Name&addressofDriver
5.DrivingLicenseNo.
6.Signatureofthevehicledriver.

DemandNo:D1607800369065(160700509730) Single(Second)

PrintedOn:22/07/201611:49:14

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