(i) Has the piece of equipment been modified to apply a manufacturer's code?
………..........................................…………………………………………………
(ii) If so, state the manufacturer's code that each such piece of equipment has been
modified to apply:……….......................................................……………………..
(iii) State the name and physical address of the consignor, and, if different, the
seller:…………………...........................................……………………………….
......................………………………………………………………………………
(iv) State the name and physical address of the consignee, and if different, the
purchaser:…………...............................…………………………………………..
…………………………………………......................……………………………
…………………………………………………………......................……………
Undertaking
I, …………………………………………………….....................................................................................................................……………………do
hereby affirm that I have the authority to furnish the information provided above and that the information
provided is to the best of my knowledge true and correct.
Name:………………………………………………………………....................................................................................................................................…….
Designation:……………………………………………………………….............................................................................................................................
Address:…………………………………………………………………...................................................................................................................................
…………………………………………………………………………….........................................................................................................................................
Signature: ………………………………
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Date: ……………………………