SCHEDULE -- XII

[See rule 6(1), 7]

Part -- I

End-use declaration

Information regarding seller of ozone depleting substances:

Name of supplier:

Address:

Information regarding purchaser of ozone depleting substances

Name of recipient:

Address:

Fax:

Telephone No.:

Registration No.:

Name and address of Registering Authority:

5.	Name of Ozone Depleting Substance	Purpose* 1 for which Ozone Depleting Substance is purchased	Quantity of Ozone Depleting Substance purchased
			Kg.
			Kg.
			Kg.
			Kg.
			Kg.
			Kg.

:69:

6. Has the purchaser ever been convicted of an offence under Indian law applicable in respect of ozone depleting substances?

Yes No

Signature of the Purchaser of the Ozone Depleting Substances

With seal*2.

Verification:

I ЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕ. S/o. ЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕ.. do hereby solemnly verify that to the best of my knowledge and belief the information given above and the annexure and statements accompanying it are correct and complete.

I further declare that I am making and verifying this declaration in my capacity as ЕЕЕЕЕЕ. and that I am competent to do so.

Place ЕЕЕЕЕЕЕЕЕЕЕЕЕЕ. Signature*3 ЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕ...

Date ЕЕЕЕЕЕЕЕЕЕЕЕЕЕ. with Seal

Note:

*1. Purposes are:

Manufacture of aerosols (excluding metered dose inhalers for medicinal purposes).

Manufacture of Foam products.

Manufacture of Fire extinguishers & Fire extinguishing systems.

Manufacture of Mobile Air Conditioners.

Manufacture of other Refrigerations & Air Conditioning products (excluding compressors).

Solvents use.

Exempted use.

Selling.

Servicing of fire extinguishers of fire extinguishing systems (applicable for Group II ODS).

Manufacture of metered dose inhalers for medicinal purposes.

Manufacture of compressors.

Others -- specify (excluding servicing).

*2. Use a separate form for quantities of ozone depleting substances for which the Central Government has granted exemption from these rules.

*3. The above Form including the verification portion must be signed in case of an individual, by himself or a person duly authorised by him; in case of Hindu undivided family, by the Karta; in case of a partnership firm, by the managing partner, in case of a company, by a person duly authorised in that behalf by the Board of Directors, and in any other case, by a person incharge of or responsible for the conduct of the business.

PART -- II

A person purchasing ozone depleting substances will produce a copy of certificate of registration issued under sub-rule (1) of rule 8 before the person selling such ozone depleting substances along with the declaration specified in part I above. The copy of such certificate of registration should have been duly attested in case of a company by the Company Secretary or a full time Director of the company, in case of a partnership firm by the Managing partner and in any other case by Public Notary or a Gazetted Government Officer. The person selling ozone depleting substances shall verify particulars given in serial numbers 2, 3 and 4 of declaration specified in part I above with the corresponding particulars mentioned in the certificate of registration.

[F. No. 16/1/96-OC]

(Dr.A.K. KUNDRA)

Special Secretary