Exporter (Name, full address, country) | Exporter's Ref. No. CARIBBEAN COMMON MARKET COMBINED DECLARATION BY EXPORTER AND CERTIFICATE OF ORIGIN Country of Issue .......................................... (country) See notes overleaf |
Consignee (Name, full address, country) |
Transport information (vessel/aircraft, place of loading, etc.) | Country of Origin | Country of Destination |
For Official Use |
Item Number | Marks and numbers of packages | Number and kind of packages, description of goods | Origin criterion (see notes overleaf) | Gross weight or other quantity | Number and date of invoices |
CERTIFICATION It is hereby certified, on the basis of control carried out, that the declaration by the exporter is correct. | DECLARATION BY THE EXPORTER I, the undersigned, hereby declare that the above details and statements are correct; that all the goods were produced in ........................ (country) and that they comply with the provisions governing the determination of origin set out in Articles 14 and 16 of and Schedule II to the Annex to the Treaty establishing the Caribbean Community. |
............................................................ | .......................................................... |
Place and date, signature and stamp of certifying authority | Place and date, signature of authorised signatory |