MRA/CUS/ASS/SHV/Form1
For official use only
Application Form for CO2 Levy or Rebate
Registry SN
CO2 SN
0.1
0.2
Name and address of manufacturer
Country of Export
0.3
0.4
Name and Address of Supplier
Vehicle Description (a) Make
(b) Model
(c) Grade
VIN/ Chassis type/Number
Engine Type/Model/Number
Engine Capacity
Fuel Type
Fuel Consumption
0.5
0.6
0.7
0.8
0.9
1.0
Transmission Type
(Please circle where appropriate)
1.1
Rims (Size)
1.2
Horsepower
1.3
1.4
Date of 1st Registration
CO2 Emission (Combined)
(100 km/litre or km/litre)
AT / MT / CVT / FAT /CAT / Tripronic/Steptronic/ 7G tronic/ Other
(UNECE 101)
N.B. Specifications of the vehicle as per catalogues, website, publications or any other reliable source
acceptable to the Director General must be attached to this form.
This is to certify that the CO2 Emission of the above mentioned imported vehicle is in accordance with
the Regulations 101 of UNECE and manufacturer’s specifications, and that all the information given
above is true and correct.
I, the undersigned, undertake to pay any additional CO2 Levy in case it is found that, after clearance
of the vehicle, there is a discrepancy in the value of the CO2 emission declared.
--------------------------------Importer’s/Rep signature
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For official use only
Approved
Rejected (for the following reasons)
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Name of CEO
Grade
Emp ID
Signature
Date
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Received by
Signature
ID
Date
(To be filled by Importer or Representative)