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FORM VAT 402 Electronic

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

Confirmed and Printed On: 03/03/2017 17:34:40

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

21W-17062613942
TIN: 21131101071

2. Consignor of goods
Name: MA - KALI ENTERPRISE

Address: 207/28 , BELILIOUS ROAD , HOWRAH - 711101


TIN: 19681759005

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


HOWRAH West Bengal (Actual/Expected Date)
3/3/2017

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 16/16-17 3/3/2017 4.0000 24,990.00

Bags

10. Vehicle / Carrier Detail - Vehicle Regd. Driver's Name Lorry / Transport / Railway
21W-17062613942
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
from any liabilities arising out of the use / misuse of this system generated Date of Approval: 3/3/2017/ 5:33:28PM 21131101071

electronic Waybill.

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