FORM VAT 402

WAY BILL

[See sub-rule (3) of rule 79]

Electronic

Date of Approval: 24/7/2013/10:38:53PM

Jharkhand

Dealer of Odisha

(To whom waybill is issued

Name:

TIN:

Name:

Address:

TIN:

Place of Despatch of goods

1.

2.

3. 4. State of Despatch of goods 5. Date of Despatch of goods

(Actual/Expected Date)

6. Name of entry/exit check gate:

Consignee of goods

Name:

Address:

TIN:

7.

CST No:

8.

Delivery to the

buyer

After purchase

by self/by agent

Branch

transfer

Consignment

sale

Execution of

works contract

Transfer of

right to use

Consigner despatching goods for [(Tick) Mark in the appropriate box]

21291502660

Shree Ram Bhandar

Mohit Udyog

Gamharia

Gamharia

24/7/2013

Shree Ram Bhandar

Bhadrak Bhadrak Charampa

21291502660 21291502660

9.

Sl.N

o

Commodity & Code Invoice / Challan (in case of

sale / Purchase) / Other

document (other than sale /

purchase)

Quantity Value (in Rs)

Jamsolaghat

Yes

WA

Y B

ILL

No

:2

1W

-131

40

15

0411

Any Other

reason,(plea

se specify)

Details of Invoice / Challan / Other document(s)

Sl. Number Date

Consignor of goods

WA

Y B

ILL

No

:21W

-13

14015

0411

atta,maida,suji-53050090 24/7/2013301 158,332.00 1

Packets

175.0000

Driver's NameVehicle / Carrier Detail - Vehicle Regd.

No.

Lorry / Transport / Railway

Receipt No.

JH02C9205

K.Sharma

10.

Owner of Vehicle Transporter's Name and Address

BIRBAL SAHU G.Transport

Way bill issuing/approving Office 12. Way bill issuing/approving authority (Name &

Desgination)

11.

Bhadrak Circle

System Generated Waybill

Declaration of the Dealer of Orissa to whom Way bill issued Seal

Date of Approval:

13.

I hereby indemnify the Government / Department / Officer (s) concerned

from any liabilities arising out of the use / misuse of this system generated

electronic Waybill.

2129150266024/7/2013/10:38:53PM