[This Declaration form can be printed in Triplicate as *Counterfoil * Duplicate * Original]

THE CENTRAL SALES TAX

(Registration & Turnover) Rules 1957
FORM "C"
FORM OF DECLARATION [See rule 12(1)]

Serial No. : 201073906161734 SEAL of Issuing Authority

Name of Issuing State : JHARKHAND
Office of Issue : Department Of Commercial Taxes
Government Of Jharkhand
Date of Issue : 12/07/2017

Name, Registration Certificate No. and address of the purchasing dealer to whom issued:
M/S PARKEM PHARMACEUTICALS PRIVATE LIMITED - 20150310230 - Jharkhand
MISHIR GONDA,J.P.MARG,KANKE ROADNA Ranchi RANCHI

Date from which registration is valid : 06/08/2014

To,
Name, Registration No. and Address of the seller/Transferor with name of the State:
LOGOS PHARMA - 05006443153 - DEHARADUN - Uttarakhand

This form of Declaration is valid only for the following:

(1) Period : 01/07/2016 - 30/09/2016
(2) Total Invoices : 1
(3) Total Value : 116427.75 Rs.

Certified that the goods,

Ordered for in our Purchase Order No and Purchase Order Date are As stated overleaf
Purpose : Please refer : # Particulars of Bill/Cash Memo/ Challan
Goods supplied as per Bill/Cash memo/Challan No. As stated overleaf dated As stated overleaf.

It is further certified that I/we am/are not registered under section 7 of the said Act in the State of
............................................ in which the goods covered by this Form are/will be delivered.

Department Of Commercial Taxes, Government Of Jharkhand Page 1 of 2

 [This Declaration form can be printed in Triplicate as *Counterfoil * Duplicate * Original]
Annexure A: TRANSACTION DETAILS IN RELATION TO FORM C

Form Serial No. : 201073906161734

Office of Issue : Department Of Commercial Taxes,Government Of Jharkhand

Name of the purchasing dealer to whom issued:

M/S PARKEM PHARMACEUTICALS PRIVATE LIMITED

Registration No. of purchasing dealer to whom : 20150310230

To,

a) Name of the seller : LOGOS PHARMA

b) Name of the state : Uttarakhand

c) TIN of : 05006443153
# Particulars of Bill/Cash Memo/ Challan:

Purchas Invoice No./ Invoice Date/ Commo

Sr Purchase Value of
e Order Purpose Challan No./ Challan Date/ dity Tax Total
No. Order No. Goods
Date STN No./ Any STN Code
1 Resale CUG-876 25/08/2016 1440 115275.00 1152.75 116427.75

Total Amount : 116427.75

Total Amount in : One Lakh Six teen Thousand Four Hundred Twenty Seven Rupees AND Seventy
Five Paisa only.
Annexure B: COMMODITY DETAILS IN RELATION TO FORM C

Commodity
Sr No. Commodity Name
Code

1 1440 Medicines and Drugs", whether patent or proprietory, as

defined in section 3 of the Drugs and Cosmetics Act, 1940
(Central Act 23 of 1940)
The above statements are true to the best of my knowledge and belief.
Signature:
Name of the person signing the declaration:
Status of the person signing the declaration in relation to the dealer:

Date:

Department Of Commercial Taxes, Government Of Jharkhand Page 2 of 2