* FROM403* Original/Duplicate/Trilicate.

(See Sub-Rule(5) of rule 51)

Declaration under section 68 of the gujrat value added Tax act,2003. (For goods entering into the state from outside the state.) To, The office in charge. Check post 1. Place from which goods are dispached : M. R. Pharma Pvt. Ltd. Lote District : RATNAGIRI .2. Place to which goods are dispached : ONGC, Ahmedabad District : Ahmedabad 3. Details of goods invoice No : 097 Date : 25.02.2012 4. Consignors Details State : MAHARASHTRA. M/s. M. R. Pharma Pvt. Ltd. Reg certification no- Plot No. B19, MIDC Lote, Tal. Khed CST NO : 27770351787C DIST- RATNAGIRI VAT TIN NO – 27770351787V PH NO : 022 23740205 FAX NO : 022 23746761 5. Nature of Transaction 1 inter state sale Yes 2. Transfer of document of little ______ 3. Depot transfer_______ 4.Consignment to branch/agent_____ 5. For job works/work contract ____ 6.Any other_6. Consignee Details State:- GUJRAT. NAME:- I/C Receipt, Saij Stores, ONGC, Ahmedabad

PH NO :- 02764223448 CST NO:- 24691600091 Mobile NO :- 9428331504 VAT TIN NO :- CANSINGMENT VALUE RS –

SR. Description of Goods. Commedity code Unit Quantity Rate of Tax Value

1 Drilling Detergent 38249023 12000 2% Rs.145133/-

7 Transporters Details :- NAME :- SHREE SAMARTH TRANSPORT CO. ADDRESS:- AT \ PO LOTE MIDC AREA TAL KHED Owners Parnes.

8. VEH NO:- GJ – 11 X 9475 L.R NO. 0957 DT – 25.02.2012 9 Driver Details :- NAME:- Kasam I Hingoraja ADDRESS:- BH-Police Line, TA-Mangrol,

Dist. Junagadh 362225

Driver License no:- GJ11 19940008159 License Issuing State: Gujarat Driver Signature:- _____________________

10. Name and the address of person in charges of goods Pradeep C Jain Plot No. B-19, MIDC Lote, Tal. Khed, Dist. Ratnagiri, Maharashtra

SEAL Place :- Lote Signature:- Date :- 25.02.2012 Designation :- Director For commercial Tax Department Check Post Entry no Reason of abnormal stoppage Result if any Vehicle Date Time

Arrival