THE WEST BENGAL VALUE ADDED TAX RULES, 2005

FORM 50AWay bill for transport of consignment of goods despatched from Outside West Bengal to any place inside West Bengal

[See rule 110B read with rule 100A,rule 103A and rule 104A]

Original/Duplicate

17/01/2013 5.32 PMPrinted On:

Waybill Key No.

Office of issue

Valid upto

1.Name and Address of the Dealer/Person Importing the goods

a)VAT RC No

b)CST RC No

c)Trade Name

d)Address of principal place of Business

e)PIN

f)PAN

2.Name and Address of the Dealer/Person from whom the goods are purchased/imported

a)VAT RC No

b)CST RC No

c)Trade Name

d)Address of principal place of Business

e)PIN

g)State of India/Union Territory of India/Countryother than India

5.Name and Address of the Transporter/Owner of the vehicle by which the goods are transported

a)Name

b)Address

6.Detail of Consignment Note/Railway Receipt/AirwayBill/Bill of Landing/ Bill of Entry or similar document

7.Total No. of Invoices/tax invoices/cash memos/bills/challans/forwarding notes(details as per Annexure to

Declaration-*I/We declare that the information furnished as above are correct to the best of my/our knowledge and belief.

Date of generation of the Waybill in form 50A

f)PAN

3.Mode of transport of goods in West Bengal

4.Registration Certificate No. of the Vehicle

c)Enrolment No. under the WB VAT Act 2003(if any)

No. Date

8.Total Value of Goods(details as per Annexure to 50 A)

9.Possible Entry location in W.B

192013014236030

Directorate of Commercial Taxes,West Bengal

17/01/2013 5.04 PM

17/02/2013

19601130083

19601130277

PIONEER INDUSTRIAL CORPORATION

, 140A,S P MUKHERJEE R, OAD,CALCUTTA

District-KOLKATA

ADAPA2258D

SAUDI BASIC INDUSTRIES CORPORATION

P.B.BOX 5101

RIYADH-11422

SAUDI ARABIA000000

FOREIGN COUNTRY

3099396.69

N S DOCK

Sea

Note a) Name of the District, if transport by roadb)Name of the railway station/port/airport,if transport by rail/sea/air

R83647158 25/12/2012

Waybill Serial No.T1920130535406220

700026

1

Name of the person signing the Waybill

Status of the person signing the Waybill [in relation to the importing dealer].

Signature

#Proprietor/Partner/Director/Authorised Person, etc1 of 2

THE WEST BENGAL VALUE ADDED TAX RULES, 2005

ANNEXURE TO WAYBILL IN FORM 50ADetails of Invoices / Tax Invoices / Cash Memos / Bills / Challans / Forwarding Notes and of goods in relationto Sl. No. 7 and Sl. No. 8 of Waybill in Form 50A

17/01/2013 5.32 PMOriginal/Duplicate

Printed On:

Valid upto

Date of generation of the waybill in Form

Office of issue

Waybill Key No.

Waybill Serial No

Directorate of Commercial Taxes, West Bengal

17/01/2013 5.04 PM

17/02/2013

192013014236030

Details of Invoice/tax invoice/cash memo/bill/challan/forwarding note etc. and description,quantity

and value of goods

T1920130535406220

Invoice/bill/challan/forwarding note etc. Name

Invoice Date

Quantity

Value ofGoodsUnit

Commodity

Nos of Packages

100553771 20/12/2012 33.00 3099396.69METRIC TON

1320 BAGSPLASTIC GRANULE,PLASTIC POWDER.

Declaration-*I/We declare that the information furnished as above are correct to the best of my/our knowledge andbelief

SignatureName of the person signing the declaration

Status of the person signing the declaration

[In relation to the importing dealer]

2 of 2