1 Exporter (Name, full address, country)

EUR. 1 No. A (1234567)

Se notes overleaf before completing this form
2. Certificate used in preferential trade between

and

(insert appropriate countries, goups of countries or territories)
3. Consignee (Name, full address, country) (Optional)

4 Country, group of countries or territory

in which the products are considered

as originating

5. Country, group of countires or territory

of destination

6. Transport details (Optional)

7. Remarks

8. Item number; Marks and numbers; Number and kind of packages(1); Description of goods

9. Gross weight (kg)

10. Invoices

(Optional)

11. CUSTOMS ENDORSEMENT

12. DECLARATION BY THE EXPORTER

I, the undersigned, declare that the goods

described above meet the conditions required

for the issue of this certificate.

(Place and date)

(Signature)

(1) If goods are not packed, indicate number of articles or state ”in bulk” as appropriate.

1 Consignee Avsändare

helena

2009-12-10

Receptionen