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SCHEDULE A-1/0-1
PERIOD : ____________________________________________________________________
AUTHORIZED DEALER : _______________________________________________________
CURRENCY : _________________________________________________________________
| Serial No. | Serial Number of E-Form | Amount | Code Number | |||
| Million | Th. | Units | Country | Commodity | ||
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Total |
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Checked By : ______________
Coded By : _______________
Stamp and Signature of Authorized Dealer
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