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.
- Certificate no.
- Date (YYYY-MM-DD)
- Supplier name
- Supplier address
- Ship stores / Equipment furnishings / Repairs / Oceanic cable supplies
- No. of packages or in bulk -Nombre de colis ou en vrac
- Quantity and description of goods supplied
1. I hereby certify that the goods described above were received on board the ship/aircraft (Vessel name – Aircraft number) at (Place) on this ___ day of ___.
- Signature (officer of ship or aircraft)
2. I hereby certify that the information given above is true and complete in every respect and that the vessel/aircraft (Name of vessel/aircraft number) qualifies for ships stores under classification No. ___.
- Signature of supplier
(Do not use this area)
3. The ship/aircraft as specified above qualifies for ships stores as stated and cleared/departed on a voyage/flight to (Name of country (or customs office in Canada))
(A) For fishing ships show duration of voyage ___ days
- On (Date of clearance – departure)
- Signature (Customs officer)
(B) In case of unusual delay in clearance explain:
(A) Section 2 is to be completed by inserting the classification number applicable to the ship or aircraft receiving supplies subject to drawback under the Goods Imported and Exported Refund and Drawback Regulations.
(B) Original of this form is required for drawback claim.
Customs date stamp
- Date modified: