Issu

e D

ate

: 16-

Jan-

2016

03:5

4 PM

Valid

upt

o : 3

0-Ja

n-20

16

[See rule 70(3)]Commercial Tax Department

Government of Madhya Pradesh

Declaration

IN

Form 49: I39A74F

Betul Circle

"e-Form 49"

Form Validity 30 January 2016

Details of MP Dealer

TIN 23354705146 Name and Address AYUSHMAAN HOMOEO HALL PRO.DR.RAJESH ARORA BETUL GANJ,BETUL GANJ, BETUL

Details of Other State Dealer

TIN 05005423877 Name and Address sbl pvt ltdplot no.3 sectore 12 iie sidcul haridwareUttaranchal

Issue Date and Time 16 January 2016 3:54 PM

S.No

Invoice No and Date Destination Goods Category TotalQuantity/Weight

Total ValueGoodsDescription

1 1502501395, 09/01/2016 betulCosmetics and toilet articles (including medicinalpreparations)

3 8062.87h.l.medicin

Place from which goods dispatched betul

Carrier ( Transport company or owner of the vehicle etc )

Name and Address

Bilty No and Date Vehicle Number

I as consignor declare that all the details given above are true and correct

Place :

Date :

To be completed in the office of the checkpost ( Not required when computer generated printed e-gate pass is given)

Date and time of Entry/Exit of vehicle at check post

Seal and Signature Date :

Designation

Signature and Name of authorized person

8062.87Total

Details of Form 49: