[A link to the Portable Document Format (PDF) of this form is provided below. The content of the form is duplicated in HTML following the PDF link. ]
I certify that:
For purposes of obtaining preferential tariff treatment, this document must be completed legibly and in full by the exporter and be in the possession of the importer at the time the declaration is made. This document may also be completed voluntarily by the producer for use by the exporter. Please print or type. If more space is needed, please use additional pages.
State the full legal name, address (including city and country), telephone number, fax number and e-mail address of the exporter.
Complete this Field if the Certificate covers multiple shipments of identical goods as described in Field 5 that are imported into Canada or Jordan for a specified period of up to 12 months (blanket period). "FROM" is the date upon which the Certificate becomes applicable to the good covered by the blanket Certificate (it may be earlier than the date this Certificate is signed). "TO" is the date upon which the blanket period expires. The importation of a good for which preferential tariff treatment is claimed based on this Certificate must occur between these dates.
If one producer, state the full legal name, address (including city and country), telephone number, fax number and e-mail address, of said producer. If more than one producer is included on the Certificate, state "VARIOUS" and attach a list of all producers, including their legal names, addresses (including city and country), telephone numbers, fax numbers and e-mail addresses, cross-referenced to the good(s) described in Field 5. If you wish this information to be confidential, it is acceptable to state "AVAILABLE TO CUSTOMS UPON REQUEST". If the producer and the exporter are the same, complete the field with "SAME".
State the full legal name, address (including city and country), telephone number, fax number and e-mail address of the importer.
Provide a full description of each good. The description should contain sufficient detail to relate it to the invoice description and to the Harmonized System (HS) description of the good. If the Certificate covers a single shipment of a good, it should list the quantity and unit of measurement of each good, including the series number, if possible, as well as the invoice number as shown on the commercial invoice. If not known, indicate another unique reference number, such as the shipping order number, purchase order number, or any other number that can be used to identify the goods.
For each good described in Field 5, identify the HS tariff classification to six digits.
For each good described in Field 5, state which criterion (A through D) is applicable. The rules of origin are contained in Chapter Four (Rules of Origin) and Annex 4.1 (Specific Rules of Origin). NOTE: In order to be entitled to preferential tariff treatment, each good must meet at least one of the criteria below.
NOTE: This criterion does not apply to goods of Chapters 39 or 50 through 63 of the HS. (Reference: Article 4-1(1)(d))
For each good described in Field 5, state "YES" if you are the producer of the good. If you are not the producer of the good, state "NO" followed by (1), (2) or (3), depending on whether this Certificate was based upon: (1) your knowledge of whether the good qualifies as an originating good; (2) your reliance on the producer's written representation (other than a Certificate of Origin) that the good qualifies as an originating good; or (3) a completed and signed Certificate for the good, voluntarily provided to the exporter by the producer.
Identify the name of the country of origin ("JO" for all originating goods exported to Canada; "CA" for all originating goods exported to Jordan).
This Field may be used when there is some observation relating to this Certificate, such as, when the good or goods described in Field 5 have been subject to an advance ruling or a ruling on the classification or value of materials. Indicate the issuing authority, the reference number, and the date of issuance.
This Field must be completed, signed and dated by the exporter. When the Certificate is completed by the producer for use by the exporter, it must be completed, signed and dated by the producer. The date must be the date the Certificate was completed and signed.