Appendix-I
Application for permission to avail of the special procedure relating to pan masala and pan
                           masala containing tobacco (Gutkha).

                              (under Rule 15 of the Central Excise Rules, 2002)


Name of the manufacturer :

Address of the manufacturing premise:



ECC No :

Address of other premises manufacturing the same products:




           I/We manufacturer of pan masala or pan masala containing tobacco, residing
at...............................taluka/tehsil ........................ district................. hereby apply to avail of the
special procedure in respect of the manufacture and removal of such goods at my/our above
mentioned premise during the period beginning with.......... and ending with ........20.., under the
provisions of Notification No                     -------------CE dated                         issued under rule 15 of the
Central Excise Rules, 2002.

        I/We further declare that pouch packing machine of following particulars shall be used or
are used by me in the above mentioned premise and I undertake to pay the total duty payable by
me in terms of the provisions laid down in the said Notification.

     S No        Make and                             No.      of        Description   of           Retail sale price of the
                 model of machine                     packing            goods     to be            pouches to be
                                                      machines           manufactured               manufactured









        I/We further undertake that any addition or removal of the packing machine would be
done under the physical supervision of the Central Excise Officer as per the procedure provided
in the notification.

2.    I/We hereby agree to abide by the provisions and conditions of the said notifications
throughout the said period.

Place:

Date:
                                                                         Name, residential address and
                                                                         signature of manufacturers or
                                                                         his/their authorised agent
                                           Appendix ­II

                                 Intimation of payment of duty
           by the manufacturer of pan masala or pan masala containing tobacco
                      under Notfication No. 38/2007-C.E. dated 19-12-2007
                    issued under Rule 15 of the Central Excise Rules, 2002 .

Name of the manufacturer :

Address of the manufacturing premise:

ECC No.:

        I/We hereby declare that we have paid a sum of Rs. .............., toward the duty liability
for the month of ....................., as per particulars given below:
         (i)     No of packing machines installed in factory
         (ii)    Retail Sale Price of the pouches
         (iii) Duty payment particulars

           Date of payment       Name and address         Amount of duty
                                 of the Bank and          paid
                                 branch









Copies of bank challans are enclosed

(                                 )

Place:

Date:
                                                          Name, residential address and
                                                          signature of manufacturers or
                                                          his/their authorised agent