Consignor/Exporter (name/address) No
Regime

No. of pages
No. of items (total)
Total no. of pkgs.
Total Customs Value

      Importer/Consignee (name/address) No
Declarant                        No.
  Ref.
Manifest No. BL/AWB No.
Mode of Transport Entry Office Port/Airport/Frontier Office Rotation No.

Identity of means of transport Nationality of Transport

Date of Arrival/Departure Location of Goods

Country whence consigned Country of first destination

Examined by

Date

 Country of final destination

Additional Information

Other Charges Amount

Summary
No. of Items

Marks & nos. Description of Goods
Customs Value CPC Tariff No. Net Weight Supply Quantity

Country Of Origin No. and Type of packages Exch. Rate

Duty/Tax Type Duty/Tax Base Base Amount Rate Duty/Tax Due

Container No.
 
   
License License Quantity License Value
Place Date
I/We hereby declare that all information and particulars mentioned herein are true and correct.
Signature and Name of Declarant/ Representative
Other Charges Amount

Summary