Received with thanks from _______________________________________________________branch, a sum of Rs.______________________________ (Rupees ____________________________ only) for the purchase of goods in respect of which a Quotation dated________________has been issued by M/S ___________________________ __________________________________________________.

In the event of failure on the part of the Supplier to supply the said goods within the period specified in the Purchase Requisition, I/We undertake and agree to refund/reimburse ______________ the full amount of Rs._____________ and all cost and consequences under and in terms of the Agency Agreement.

For and on behalf of
[Insert name of the Agent)

______________________
Authorized Signatory

Date: ______________________