Government of Madhya Pradesh

Commercial Tax Department

Form No:

Bhopal Circle-2

Form 49
[See rule 70(3)] DECLARATION
Details of the dealer whom issued Name Address Door No./Shop No. Village District Phone No The Consignor Name of the other state: BHOPAL GRAM-LAMBAKHEDA Street/Complex Town City Ward No Mobile No BERASIA ROAD BHOPAL C 7898177800 BHOPAL COLD STORAGE TIN 23099023702

SUPER REFRIGERATION INDIA PVT LTD

Address WH-62 , MAYAPURI INDUSTRIAL AREA, PHASE-1, NEW DELHI-64

Place from which the goods dispatched: Place New Delhi

Carrier (transport company or owner of the vehicle etc): Name Vehicle Number

Address

Bilty/LR No.

Bilty/LR Date

I, ____________________declare that to the best of my knowledge and belief the above statements are true and correct. Place: Date: To be completed in the office of the checkpost: Date and time of arrival of the vehicle at the check post: Date and time of departure of the vehicle from the check post: Reasons for abnormal detention of the vehicle at the check post: Seal and signature of the consignor of the goods

Seal

Date Designation Signature

Please take the print of overleaf details of this form on the backside of main page. PLEASE DO NOT TAKE THE PRINT OF OVERLEAF DETAILS ON SEPARATE SHEET.

Form No: Overleaf details of form 49: Sr.No Consignor's Invoice No Consignor's Invoice Date Destination Place(including complete address) Brief description of goods Total Quantity/Total weight Units Other Description Total Value

Place: Date:

Seal and signature of the consignor of the goods