2240729000750610159168923

Part FORM 402

(See rule 51)
(For movement of goods within the State or goods moving outside the State)

Declaration under Section 68 of the Gujarat Value Added Tax Act, 2003
(This form will be considered complete only after submission of transportation details by transporter)

Form No. 99845727664

Date: 10-OCT-2015 10:44:06 AM
To,
The officer in charge
Check post SONGADH
(1) Place from which goods are dispatched : Gujarat
District :
(2) Place to which goods are dispatched : Andhra Pradesh
District :
(3) Details of goods :

Sr. No.
1

Invoice No.
21

Invoice Date
09/10/2015

(4) Consignors details :-

Name
Address
Date
CST No.

ROHIT PRO.STORES
47,PARSHWANATH SOCIETY,NR. CHAR
RASTA,NARANPURA,AHMEDABAD,07,AHMEDABAD-380013
01/07/2002
24572900075

State
Registration No.

Gujarat
24072900075

Telephone
Fax No.

7481492

Registration No.
Date
CST No.
Date

28360149045

(5) Nature of Transaction : INTERSTATE SALE

(6) Consignees details :-

Name
Address
Telephone
Fax No.

Amit Industry
6 1 103 91 padmarao Nagar Secundrabad

Consigned Value Rs.17850

Sr.
No.
1

Description of Goods
All goods not specified elsewhere

Commodity
Unit
Unit
Rate of Commodity
Code
Quantity Measure
Tax
Value
99109000
250
Ltrs
2
17850

Invoice No.
21

(7) Transporters Details :

(a) Name : Shri Nivasa Transport

(8) Vehicle No : i)
(9) Drivers Details:

ii)

L.R.No. :

Date :

(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.

Date
Date: ________________

Reason of
Abnormal
stoppage

Result if any

Time
Designation: _________________

Vehicle

Arrival
Depart
Status: _________________