Government of Madhya Pradesh "e-Form 49" Form 49: I6E54F6

[See rule 70(3)]

Commercial Tax Department
Declaration

IN
Jabalpur Circle-3

Issue Date and Time 21 February 2017 5:48 PM Form Validity 07 March 2017

Details of MP Dealer
TIN 23696000976 Name and Address M/S. KOHLI AUTOMOBILES,
2075, BUS STAND, WRIGHT TOWN, JABALPUR, JABALPUR, Madhya Pradesh

Details of Other State Dealer

TIN 03721115060 Name and Address Sehgal Automobiles
Ludhiana

17
Punjab

Details of Form 49:

7- M -20
S. Invoice No and Date Destination Goods Category Goods Total Total Value
No Description Quantity/

17
Weight
1 5675, 16/02/2017 Jabalpur Tractor, accessories and parts thereof 20 44251

:0 P B

20
Total 44251
to 48 -FE
Place from which goods dispatched Ludhiana

R-
Carrier ( Transport company or owner of the vehicle etc )
Name and Address
Bilty No and Date Vehicle Number
up 5: 21

MA
I as consignor declare that all the details given above are true and correct
Place :
:
te

Date : Signature and Name of authorized person

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

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

Seal and Signature Date :

ue

Designation
Iss

lid
Va