Application form for export of controlled substance in Schedule-B - See sub-clause (2) of clause 10 - Narcotic Drugs and Psychotropic Substances (Regulation of Controlled Substances) Order, 2013

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....g authority (name, address and tele-facsimile numbers) : Narcotics Commissioner of India, Central Bureau of Narcotics, Ministry of Finance, 19, The Mall, Morar, Gwalior, Madhya Pradesh-474006, INDIA Tel. No. : 91-751-2368121 and 2368996/2368997 Fax No. : 91-751-2368111/2368577 Website: http://cbn.nic.in, https://cbnonline.gov.in Email: [email protected], [email protected] 6. Other operator/agent (name and address) 7a. Import Certificate/ NOC No. : 7b. Issuing authority (name and address) : Telephone No: Fax number: 8. Ultimate Consignee (in case of re-sale) (name and address) : 9. Point of exit from India : 10. Mode of transport : 11. Point of entry into importing country: 12. Route : ....

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....rences and dates for last 3 exports. (1) ............................................................ (2) ............................................................ (3) ............................................................ YES/NO 21. Is the consignee a new customer for this chemical. If so, what is nature of customer's business? ............................................................ To what use will the chemicals be put? ............................................................ YES/NO 22. Was the order made directly or through a broker? If through broker please provide name and address : ............................................................ ......................

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....cturer along with the quantity and price thereof. Copy of the drug licence of the supplier/ manufacturer of the controlled substance(s), wherever applicable.   29. Declaration by applicant: I confirm that, to the best of my belief, all the information provided in this application is true. Signature :...................... Position in company/firm : Stamp/ Seal Name : .......................... (Applicant) Representing :........................... Date............................... List of documents to be submitted along with application form (i) copy of the registration under sub-clause (1) of clause 4 of this order if the controlled substance is also in Schedule-A (ii) Purchase order placed by the ....