1.

Designation and address of the applicant (If the applicant is not the adjudicating authority, a copy of the authorisation from the Commissioner of Central Excise to make the application should be enclosed).

2.

Name and address of the respondent.

3.

Designation and address of the officer passing the decision or order in respect of which this application is being made and the date of the decision or order.

4.

Date on which order under sub-section (1) of section 35E has been passed by the Board.

5.

Date of communication of the order referred to in (3) above in the adjudicating authority.

6.

(i) Description and classification of goods

(ii) Period of dispute

(iii) Amount of duty, if any, demanded for the period mentioned in
column (ii)  

(iv) Amount of refund, if any, claimed for the period mentioned in
column (ii)  

(v) Amount of fine imposed

(vi) Amount of penalty imposed

(vii) Market value of seized goods.

6.

Reliefs claimed in the application.

Note :

The form of application including statement of facts and grounds of application shall be filed in duplicate and accompanied by two copies of the decision or order passed by the adjudicating authority (one of which at least shall be a certified copy) and a copy of the order of the Commissioner of Customs.