FORM VAT 402 Electronic

WAY BILL
[See sub-rule (3) of rule 79]

Confirmed and Printed On: 06/03/2017 16:48:59

1. Dealer of Odisha
(To whom waybill is issued
Name: INDUSTRIAL CHAIN AND MILLS STORE

21W-17065285402
TIN: 21131101071

2. Consignor of goods
Name: PUJA ENTERPRISE

Address: 2/1 D , BIDHAN SARANI , KOLKATA - 700006

TIN: 19351234027

3. Place of Despatch of goods 4. State of Despatch of goods 5. Date of Despatch of goods

KOLKATA West Bengal (Actual/Expected Date)
6/3/2017

6. Name of entry/exit check gate: Laxmannath

WAY BILL No:

7. Consignee of goods
Name: INDUSTRIAL CHAIN AND MILLS STORE

Address: PLOT NO-144 KHURDA LAXMISAGAR CUTTACK ROAD

TIN: 21131101071 CST No: 21131101071

8. Consigner despatching goods for [(Tick) Mark in the appropriate box]

Delivery to the After purchase Branch Consignment Execution of Transfer of Any Other
buyer by self/by agent transfer sale works contract right to use reason,(plea
se specify)
Yes

9. Details of Invoice / Challan / Other document(s)

Sl.N Commodity & Code Invoice / Challan (in case of Quantity Value (in Rs)
o sale / Purchase) / Other
document (other than sale /
purchase)
Sl. Number Date
1 Hardware goods-7290 1364/16-17 6/3/2017 5.0000 19,425.00

Pieces

10. Vehicle / Carrier Detail - Vehicle Driver's Name Lorry / Transport / Railway
21W-17065285402
Regd. No. NA Receipt No.
NA NA

Owner of Vehicle Transporter's Name and Address

NA ORC

11. Way bill issuing/approving Office 12. Way bill issuing/approving authority (Name &
Desgination)
Bhubaneswar I Circle
WAY BILL No:

System Generated Waybill

13. Declaration of the Dealer of Orissa to whom Way bill issued Seal
I hereby indemnify the Government / Department / Officer (s) concerned
6/3/2017/ 4:47:33PM 21131101071
from any liabilities arising out of the use / misuse of this system Date of Approval:
generated electronic Waybill.