FORM IV
(To be submitted in seven copies)
[See Paragraphs 2,8,9 and 10]

Form of application for approval or revision of price of Scheduled formulations imported in finished form.

  1. Name of the company
  2. Address of the Registered/Head Office/Factory, if any.
  3. Reference to Permission, if any. Given by Drug Control Authorities for import/sale of the item.
  4. Name of the imported formulation/therapeutic group.
  5. Type of formulation (capsule/tablet/inj./ etc.)
  6. Composition of the formulation.
  7. Type of Packs(strip/vial/ampoule etc.)
  8. Pack size (10's etc/10 ml etc/5 gms etc.)
  9. Country from which imported and date of import.
  10. Quantity / Number of packs imported with Batch/Lot Number.
  11. C.I.F. Value in Foreign Currency.

(Not to include bank commission, interest etc.)
Total      Per pack
(Rs.)       (Rs.)

  1. C.I.F. Value in Rs. Actually paid. (not to be include bank commission, interest etc.)
  2. Duty of customs, if any, actually paid
  3. Clearing Charges (with details) actually incurred.
  4. Landed cost (12+13+14).
  5. Packing materials, if any, as per norms.
  6. Packing charges, if any, as per norms.
  7. Landed cost (including repacking cost, if any). (15+16+17)
  8. Margin @ 50%
  9. Duty of Excise, if any
  10. Retail price claimed (18+19+20)
  11. Existing retail price, if any:

(copy of approval letter to be enclosed)

NOTES:-

  1. Information furnished should be certified by the Authorised Signatory of the company and a cost/chartered accountant.
  2. In respect of sl.nos. 11 to 14 and 16, the claims shall be supported by certified copies of documentary evidence.

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The information furnished above is correct and true to the best of my knowledge and belief.

                            Authorised Signatory:

Place:                   Name:
Date:                    Designation:

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