(ELECTRONIC COPY)

1. Goods consigned from (exporter's business name, address, country) Reference No. EIC/2024/003/0829401A/00767623
DOMS INDUSTRIES LIMITED SOUTH ASIAN FREE TRADE AREA
OLD SURVEY NO 39/P1/P32, 39/P1/P33, 39/P1/P34, 39/P1/P35,, VILLAGE (SAFTA)
DEHRI UMBERGAON, GUJARAT (396171) (combined declaration and certificate)
INDIA
2. Goods consigned to (Consignee's name, address, country)
Issued in INDIA
......................................................
PUSHPANJALI DISTRIBUTORS PVT. LTD.
(country)
THAPAGAUN WARD NO. 10, BANESHWOR, KATHMANDU, NEPAL PAN / VAT
NO. 604304342 / EXIM: 6043043420130NP
NEPAL see notes overleaf
3. Means of Transport and route (as far as known) 4. For official use
By Road
FROM UMBERGAON, GUJARAT, INDIA TO CHANDRAGIRI NAGARPALIKA WARD
NO. 10, KATHMANDU, NEPAL VIA BHAIRAHAWA CUSTOMS OFFICE, BHAIRAHAWA,
NEPAL
5. HS Code 6. Marks and 7. Number and kind of packages; 8. Origin 9. Gross 10. Number and 11. f.o.b. value in
numbers of description of goods criterion(see weight or date of invoice US $
packages notes overleaf) other
quantity
9608 2000 15 CTNS TOTAL 184 CARTONS ONLY. DOMS SKETCH FINE "A" 337.50 kg 9906240231 USD 666.85
WATER COLOUR PEN POUCH 12 SHADES
DT: 22/09/2024
9609 1000 10 CTNS DOMS SUPERIOR SUPER DARK PENCIL TIN PACK "A" 255.30 kg USD 1233.29
12 PCS
9609 1000 64 CTNS DOMS VICTORY PENCILS 10 PCS "A" 2016.00 kg USD 5122.12
9608 2000 20 CTNS DOMS WOW KIT "A" 445.60 kg USD 1109.77
9608 2000 35 CTNS DOMS F9LINER 10 SHADES PENS "A" 386.05 kg USD 1960.67
3407 0010 15 CTNS DOMS ART ZANIA KIT "A" 240.00 kg USD 768.63
4016 9200 25 CTNS DOMS MINI E-RACER ERASER "A" 580.25 kg USD 897.46
12. Declaration by the exporter: 13. Certificate
The undersigned hereby declares that the above details and It is hereby certified, on the basis of control carried out that the
statements are correct: that all the goods were produced in declaration by the exporter is correct.
To verify this certificate, you may scan the QR code here
INDIA
..........................................................................................................
(country)

and that they comply with the origin requirements specified

for those goods in SAFTA for goods exported to
NEPAL
..........................................................................................................
(importing country)

MUMBAI, 30/09/2024
.................................................................................................
Place and date, signature of the authorised signatory

RANJEET K K, Mumbai, 01/10/2024

.............................................................................................
Place and date, signature and Stamp of Certifying authority
I. General Conditions

To qualify for preference, products must :

(a) fall within a description of products eligible for preference in the schedule of concessions of SAFTA country of destination;

(b) comply with SAFTA Rules of Origin. Each article in a consignment must qualify separately in its own right; and

(c) comply with the consignment conditions specified by the SAFTA Rules of Origin. In general, products must be consigned
directly within the meaning of Rules 12 hereof from the country of exportation to the country of destination.

II. Entries to be made in Box 8

Preference products must be wholly produced or obtained in the exporting Contracting State in accordance with Rule 5 of the
SAFTA Rules of Origin, or where not wholly produced or obtained in the exporting Contracting States must be eligible under Rule
6.

(a) Products wholly produced or obtained ; enter the letter "A" in Box 8

(b) Products not wholly produced or obtained : the entry in Box 8 should be follows :

(1) Enter letter "B" in Box 8, for products which meet the origin criteria according to Rule 8. Entry of letter would be
followed by the value of non-originating material expressed as a percentage of the f.o.b. value of the products;
(example "B" 50 per cent)

(2) Enter letter "C" in Box 8 for products which meet the origin criteria according to Rule 9. Entry of letter "C" would be
followed by the sum of the aggregate content originating in the territory of the exporting Contracting State expressed
as a percentage of the f.o.b. value of the exported product; (example "C" 60 per cent)

(3) Enter letter "D" in Box 8 for products which meet the special origin criteria according to Rule 10. Entry of letter would
be followed by the value of non-originating material expressed as a percentage of the f.o.b. value of the product;
(example "D" 40 per cent)

III. Entries to be made in Box 4

In case of issuance of certificates retrospectively Box 4 should bear the words "ISSUED RETROSPECTIVELY".

IV. Entries to be made in Box 13

In case of issuance of certified true copies Box 13 should bear the words "CERTIFIED TRUE COPY".
1. Goods consigned from (exporter's business name, address, Reference No. EIC/2024/003/0829401A/00767623
country) SOUTH ASIAN FREE TRADE AREA
DOMS INDUSTRIES LIMITED (SAFTA)
OLD SURVEY NO 39/P1/P32, 39/P1/P33, 39/P1/P34, 39/P1/P35,, VILLAGE (combined declaration and certificate)
DEHRI UMBERGAON, GUJARAT (396171)
INDIA
Issued in INDIA
......................................................
2. Goods consigned to (Consignee's name, address, country) (country)
PUSHPANJALI DISTRIBUTORS PVT. LTD.
THAPAGAUN WARD NO. 10, BANESHWOR, KATHMANDU, NEPAL PAN / VAT
NO. 604304342 / EXIM: 6043043420130NP see notes overleaf
NEPAL

3. Means of Transport and route (as far as known) 4. For official use
By Road
FROM UMBERGAON, GUJARAT, INDIA TO CHANDRAGIRI NAGARPALIKA WARD
NO. 10, KATHMANDU, NEPAL VIA BHAIRAHAWA CUSTOMS OFFICE, BHAIRAHAWA,
NEPAL
5. HS Code 6. Marks and 7. Number and kind of packages; 8. Origin 9. Gross 10. Number and 11. f.o.b. value in
numbers of description of goods criterion(see weight or date of invoice US $
packages notes overleaf) other
quantity
9608 2000 15 CTNS TOTAL 184 CARTONS ONLY. DOMS SKETCH FINE "A" 337.50 kg 9906240231 USD 666.85
WATER COLOUR PEN POUCH 12 SHADES
DT: 22/09/2024
9609 1000 10 CTNS DOMS SUPERIOR SUPER DARK PENCIL TIN PACK "A" 255.30 kg USD 1233.29
12 PCS
9609 1000 64 CTNS DOMS VICTORY PENCILS 10 PCS "A" 2016.00 kg USD 5122.12
9608 2000 20 CTNS DOMS WOW KIT "A" 445.60 kg USD 1109.77
9608 2000 35 CTNS DOMS F9LINER 10 SHADES PENS "A" 386.05 kg USD 1960.67
3407 0010 15 CTNS DOMS ART ZANIA KIT "A" 240.00 kg USD 768.63
4016 9200 25 CTNS DOMS MINI E-RACER ERASER "A" 580.25 kg USD 897.46
12. Declaration by the exporter: 13. Certificate
The undersigned hereby declares that the above details and It is hereby certified, on the basis of control carried out that the
statements are correct: that all the goods were produced in declaration by the exporter is correct.
To verify this certificate, you may scan the QR code here
INDIA
..........................................................................................................
(country)

and that they comply with the origin requirements specified

for those goods in SAFTA for goods exported to
NEPAL
..........................................................................................................
(importing country)

MUMBAI, 30/09/2024
.................................................................................................
Place and date, signature of the authorised signatory

RANJEET K K, Mumbai, 01/10/2024

.............................................................................................
Place and date, signature and Stamp of Certifying authority
I. General Conditions

To qualify for preference, products must :

(a) fall within a description of products eligible for preference in the schedule of concessions of SAFTA country of destination;

(b) comply with SAFTA Rules of Origin. Each article in a consignment must qualify separately in its own right; and

(c) comply with the consignment conditions specified by the SAFTA Rules of Origin. In general, products must be consigned
directly within the meaning of Rules 12 hereof from the country of exportation to the country of destination.

II. Entries to be made in Box 8

Preference products must be wholly produced or obtained in the exporting Contracting State in accordance with Rule 5 of the
SAFTA Rules of Origin, or where not wholly produced or obtained in the exporting Contracting States must be eligible under Rule
6.

(a) Products wholly produced or obtained ; enter the letter "A" in Box 8

(b) Products not wholly produced or obtained : the entry in Box 8 should be follows :

(1) Enter letter "B" in Box 8, for products which meet the origin criteria according to Rule 8. Entry of letter would be
followed by the value of non-originating material expressed as a percentage of the f.o.b. value of the products;
(example "B" 50 per cent)

(2) Enter letter "C" in Box 8 for products which meet the origin criteria according to Rule 9. Entry of letter "C" would be
followed by the sum of the aggregate content originating in the territory of the exporting Contracting State expressed
as a percentage of the f.o.b. value of the exported product; (example "C" 60 per cent)

(3) Enter letter "D" in Box 8 for products which meet the special origin criteria according to Rule 10. Entry of letter would
be followed by the value of non-originating material expressed as a percentage of the f.o.b. value of the product;
(example "D" 40 per cent)

III. Entries to be made in Box 4

In case of issuance of certificates retrospectively Box 4 should bear the words "ISSUED RETROSPECTIVELY".

IV. Entries to be made in Box 13

In case of issuance of certified true copies Box 13 should bear the words "CERTIFIED TRUE COPY".
1. Goods consigned from (exporter's business name, address, Reference No. EIC/2024/003/0829401A/00767623
country) SOUTH ASIAN FREE TRADE AREA
DOMS INDUSTRIES LIMITED (SAFTA)
OLD SURVEY NO 39/P1/P32, 39/P1/P33, 39/P1/P34, 39/P1/P35,, VILLAGE (combined declaration and certificate)
DEHRI UMBERGAON, GUJARAT (396171)
INDIA
2. Goods consigned to (Consignee's name, address, country) Issued in INDIA
......................................................
(country)
PUSHPANJALI DISTRIBUTORS PVT. LTD.
THAPAGAUN WARD NO. 10, BANESHWOR, KATHMANDU, NEPAL PAN / VAT
NO. 604304342 / EXIM: 6043043420130NP see notes overleaf
NEPAL

3. Means of Transport and route (as far as known) 4. For official use
By Road
FROM UMBERGAON, GUJARAT, INDIA TO CHANDRAGIRI NAGARPALIKA WARD
NO. 10, KATHMANDU, NEPAL VIA BHAIRAHAWA CUSTOMS OFFICE, BHAIRAHAWA,
NEPAL

5. HS 6. Marks and 7. Number and kind of packages; 8. Origin 9. Gross 10. Number 11. f.o.b. value in
Code7 numbers of description of goods criterion(see weight or and date of US $
packages notes overleaf) other invoice
quantity

9608 2000 15 CTNS TOTAL 184 CARTONS ONLY. DOMS SKETCH "A" 337.50 kg 9906240231 USD 666.85
FINE WATER COLOUR PEN POUCH 12 SHADES
DT: 22/09/2024

9609 1000 10 CTNS DOMS SUPERIOR SUPER DARK PENCIL TIN PACK "A" 255.30 kg USD 1233.29
12 PCS
9609 1000 64 CTNS DOMS VICTORY PENCILS 10 PCS "A" 2016.00 kg USD 5122.12
9608 2000 20 CTNS DOMS WOW KIT "A" 445.60 kg USD 1109.77
9608 2000 35 CTNS DOMS F9LINER 10 SHADES PENS "A" 386.05 kg USD 1960.67
3407 0010 15 CTNS DOMS ART ZANIA KIT "A" 240.00 kg USD 768.63
4016 9200 25 CTNS DOMS MINI E-RACER ERASER "A" 580.25 kg USD 897.46
12. Declaration by the exporter: 13. Certificate
The undersigned hereby declares that the above details and It is hereby certified, on the basis of control carried out that the
statements are correct: that all the goods were produced in declaration by the exporter is correct.
INDIA To verify this certificate, you may scan the QR code here
..........................................................................................................
(country)
and that they comply with the origin requirements specified
for those goods in SAFTA for goods exported to
NEPAL
..........................................................................................................
(importing country)

MUMBAI, 30/09/2024
.................................................................................................
Place and date, signature of the authorised signatory

RANJEET K K, Mumbai, 01/10/2024

.............................................................................................
Place and date, signature and Stamp of Certifying authority
 APPLICATION FOR CERTIFICATE OF ORIGIN

The undersigned, being the exporter of the goods described overleaf,

DECLARES that these goods were produced in INDIA

SPECIFIES as follows the grounds on which the goods are claimed to comply with SAFTA origin requirements,1)

UMBERGAON, GUJARAT, INDIA, GOODS ARE WHOLLY OBTAINED IN INDIA & MEETS THE ORIGIN REQUIREMENT OF SAFTA

SUBMITS the following supporting documents,2)

INVOICE / PACKING LIST

UNDERTAKES to submit, any additional supporting evidence which the Certifying Authority may require for the purpose of issuing a
certificate of origin and undertakes, if required, to agree to any inspection of his accounts and any check on the process of manufacture
of the above goods, carried out by the said authority.

REQUESTS the issue of a certificate of origin for these goods.

.........................................................................
(Signature & stamp of the authorized signatory)

Place and date MUMBAI, 30/09/2024

..............................................................

1)
To be completed if materials or components originating in another country have been used in the manufacture of the goods in
question. Indicate the value of imported materials and components used (including those of undetermined origin), their country of
origin and the f.o.b. value of the exported goods.

2)
For example, import documents, invoices etc., relating to the materials or components used.

NOTES

A. Procedure for claiming perference. A declaration on the certificate of origin form must be prepared by the exporter of the goods
and submitted in duplicate, together with a SAFTA application form, to the Indian Certifying Authority which will, if satifsifed, certify
the top copy of the cerficate of origin and return it to the exporter for transmission to the importer in the country of destination. The
Certifying Authority will itself retain the Duplicate Copy.

B. Sanctions Persons who furnish, or cause to be furnished, information which relates to origin or consignment, and which is untrue
in a material particular are liable to legal penalities and to the suspension of facilities for their goods to obtain preference.

% DSUnknown
q
1G
1g
0.1 0 0 0.1 9 0 cm
0 J 0 j 4 M []0 d
1i
0g
313 292 m
313 404 325 453 432 529 c
478 561 504 597 504 645 c
504 736 440 760 391 760 c
286 760 271 681 265 626 c
265 625 l
100 625 l
100 828 253 898 381 898 c
451 898 679 878 679 650 c
679 555 628 499 538 435 c
488 399 467 376 467 292 c
313 292 l
h
308 214 170 -164 re
f
0.44 G
1.2 w
1 1 0.4 rg
287 318 m
287 430 299 479 406 555 c
451 587 478 623 478 671 c
478 762 414 786 365 786 c
260 786 245 707 239 652 c
239 651 l
74 651 l
74 854 227 924 355 924 c
425 924 653 904 653 676 c
653 581 602 525 512 461 c
462 425 441 402 441 318 c
287 318 l
h
282 240 170 -164 re
B
Q

Digitally signed by
RANJEET K KOOVERI
Date: 2024.10.01
14:48:15 IST

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