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(iii) is a holder of Import-Export Code Number;

(iv) is registered under section 69 of the said Act;

(v) is liable to pay service tax under sub-section (2) of section 68 of said Act, read with sub-clause (iv) or sub-clause

(v) of clause (d) of sub-rule (1) of rule 2 of the Service Tax Rules,1994, for the specified service;

(b) the invoice, bill or challan, or any other document issued by the service provider to the exporter, on which the exporter intend to avail exemption, shall be issued in the name of the exporter, showing that the exporter is liable to pay the service tax in terms of item (v) of clause (a);

3. Division ......... Commissionerate ...............

5 Name of the Export Council

6. Address of the registered / head office of exporter:

7. Tel. No. and e-mail ID of the exporter........:

8. Import -Export Code No..............

9. Details of Bank Account (Name of Bank, branch address and account number) I/we undertake that I/we shall comply with the conditions laid down in the said notification and in case of any change in aforementioned particulars, I/We shall intimate the same.

1. Name of the exporter.

2. Address of the registered / head office of exporter

3. Tel. No. and e-mail ID of the exporter........:

4. Service Tax Registration No.

5. Division ......... Commissionerate ...............

6. Membership No. Of the Export Council

7. Import Export Code No..............

8. Name of the Export Council

9. Details of Bank Account (Name of Bank, branch address and account number) Table A S. Details of goods exported (on which exemption of service tax availed) during No. the six months ending on................................