Ref. FE Circular No.
17/2019 Annexure-A
EXP FORM
(Submitted electronically by exporter)
Statutory declaration to be furnished by exporters under Foreign Exchange Regulation Act, 1947 before
shipment of goods. An incorrect declaration constitutes offence under the said Act.
Electronic Declaration No. : 00000271 /000223 /2025 Date: 22-JUN-2025
Name and address of the Authorized Dealer: Rupali Bank PLC., S K Road Branch (00000271)
Detail of Export
S1 Item Particulars Code No. (to be filled in
No (to be filled in by exporter) by Authorized Dealer)
Commodity to be exported 61052000 : 61052000-MEN'S OR BOYS' SHIRTS,KNITTED OR
1. CROCHETED...-Men'S Or Boys' Shirts Of Man-Made Fibres, Knitted Or
Crocheted
2. Country of destination ES 2016
3. Port of destination ANY PORT IN SPAIN
Unit (bales/tons/Ibs. etc.) Pieces
4. Quantity Volume Weight/number
1170
etc)
Currency US DOLLAR 001
Inco-terms Used FCA
5. Value FOB Insurance Freight
Invoice Value 1462.5
1462.5 0 0
ank
CMT value (if applicable) 0
Terms of sale (firm contract/LC or
6. Consignment sale) Contract, ROGERSEV/04/2025, 10-APR-2025
Name & address of
7. ROGERSEV, S.L, SPAIN
importer/consignee
8. Name of carrying vessel
Bill of Lading/Railway Receipt/Airway
9. Bill/Truck Receipt/ Post Parcel
Receipt
hB
Port of shipment/Post Office of
10. SHAHAJALAL INT. AIRPORT
dispatch
11. Land Custom Post
12. Shipment date
Name of the exporter (in block letter)
13. with address. M/S. LATEST FASHION
des
CCI &E's Registration Number and
14. date of the exporter 260326210752220
Sector (Public or Private) under which
15. the Exporter falls PRIVATE
Declaration of undertaking by Exporter
gla
I/We, the undersigned hereby declare that I/we am/are the sellers/consignors of the goods described below in respect of which this
declaration is made out and that the particulars given in the following items are true and that the invoice value declared in SI.No.5 in
case of firm contract is full value as contracted with the buyers/in case of consignment sale, is a fair value of the goods which are being
shipped on consignment sale.
Aminul Islam
Ban
Date: Authorized Signature & Stamp
of the Exporter with date.
Certificate of Authorized Dealer
Certified that the above exporter(s)is/are known to us, that he/they is/are bonafide businessman/men in Bangladesh and that he/they has/have made
arrangements with us for the realisation of the export proceeds of the goods declared on this form within four months from the date of shipment and that
we are satisfied with the said arrangements. We have also satisfied ourselves about the bonafides of the importers/consignees abroad and their
credentials etc.
*We undertake to ensure that export proceeds against shipment on firm contract shall be received by us within the stipulated period of four months. In
the event of noncompliance due to reasons beyond our control we shall furnish to the Bangladesh Bank a full explanation as to the reasons and
circumstances resulting in our inability to comply.
*We undertake that in the event of nonrealisation of export proceeds against shipment on consignment sale within the stipulated period of four months,
we shall obtain from the exporter (s) and furnish to the Bangladesh Bank a full explanation as to the circumstances resulting in nonrealisation. We further
undertake that in the event of short realisation, we shall obtain from the exporter(s) and furnish to the Bangladesh Bank a fully documented account sale
certified by the consignees/Chamber of Commerce of the country of import.
*(Strike out the portion not applicable and authenticate with initials).
Date: Stamp and Signature of
Authorized Dealer
