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Name, Registration Certificate No. and Address of the Purchasing Dealer to whom issued
WELSPUN INDIA LIMITED - 24750400336, Gujarat
SURVE NO 76,MORAI,MORAI,MORAI,PARDI,VALSAD-396191
Certified that the goods ordered for in our purchase order No ...................... dated ..................... and
supplied as per Bill/Cash memo/Challan No. .................. dated ..................... as stated below purchased
from you as per Bill/cash memo/Challan No.....................dated...............as stated below are for
resale...................use in manufacture/processing of goods for sale use in mining use in
generation/distribution of power-packing of goods for sale/resale and are covered by my/our registration
certificate No...................dated...............issued under the Central Sales tax Act, 1956.
It is further certified that I/we am/are not registered under section 7 of the said Act in the State of
............................................ in which the goods covered by this Form are/will be delivered.
The above statements are true to the best of my knowledge and belief.
Name and Signature of the person signing the declaration
Date:
Status of the person signing the declaration in relation to the dealer ...............................................................
....................................................................................
...........................................................................................................................................................................
.
# Particulars of Bill/Cash Memo/ Challan:
Date ........................................... No. ................................................. Amounts(Rs.) ......................................
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[This Declaration form can be printed in Triplicate as *Counterfoil * Duplicate * Original]
Annexure A: TRANSACTION DETAILS IN RELATION TO FORM C
Form Serial No. : 241038435511321
Office of Issue : Commercial Tax, Gujarat
Name of the purchasing dealer to whom issued : WELSPUN INDIA LIMITED
Registration of purchasing dealer to whom issued : 24750400336
To
a) Name of the seller A J BELTINGS
b) Name of the state Maharastra
c) TIN of the seller 27250546745
Sr No. Invoice No Invoice Date Value of Goods Tax Total
1 EXT407 11/10/2012 3622 71 3693
Total Amount : Rs. 3693
The above statements are true to the best of my knowledge and belief.
Signature
Name of the person signing the declaration
Date
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