ORIGINAL EXPORTER or PRODUCER – Name and contact details CERTIFICATE No. 輸出者／生産者の名称、住所及び国名 EXPORTERS REFERENCE 原則として日本への輸入に用いられるインボイス（第三国インボイスを含む。）の番号・日付。 (Optional) Importer – name and contact details. 輸入者の名称、住所及び国名 Australia – Japan Economic Partnership Agreement AUSTRALIAN INDUSTRY U GROUP CERTIFICATE OF ORIGIN Level 2, 441 Stt Kilda K Road MELBOURNE VICTORIA R 3004 AUSTRALIA T: +61 (0)3 9867 0111 1 F: -61 (0)3 9867 0157 The Australian Chamber of Manufactures an has merged with the MTIA to us form the Australian Industry Group Invoice Number Date of Invoice インボイスの日付インボイスの番号 HARMONIZED SYSTEM CODE (SIX DIGITS) Date of Shipment PREFERENCE CRITERION 船積日 DESCRIPTION OF GOODS: (WO, PE, PSR) 産品のHS番号（2012年版）原産地基準産品の詳細（産品名、重量、数量等）・産品毎に HS６桁レベルで・産品毎に・産品名等の記載は産品の仕入書における品名とHS 関税分類を十 WO、PE、PSR 分関連付けられるようにする。のHS番号を記載しなけれの原産地基準をばならない。記載する。輸出者（又は代理人）による記入。 I certify that: 空欄にはそれぞれ - The information in this document is true and accurate urate rate and I assume the responsibility for proving such representations. repres I ①原産地証明書の枚数 understand that I am liable for any false statements or ②輸出者(又は代理人)署名（自署又は電子的印刷） material omissions made on or in connection with this ddocument. - I agree to maintain, and present upon request, est ddocumentation necessary to support this Certificate, and tto inform, in ③輸出者（又は代理人）の名称 writing, all persons to whom the Certificatee was of any changes that would affect the accuracy or val validity of this w given va ④輸出者管理ID Certificate. を記入。 - The goods originate in the territory of one or both oth th Parties and comply with the origin requirements specified specif specifi for those goods in the Australia – Japan Economic mi Partnership Agreement. ① pages, including all attachments. This Certificate consists of ______ ② SIGNED: ................................. EXPORTER REGISTRATION ID: ④ ……………… 輸出締約国の権限ある当局又は発給機関による記入。・発給職員氏名・発給職員署名（自署又は電子的印刷） ①第三国インボイス ④ 及発給 This Certificate is based sed on the information supplied to the Designated Issuing Authority by the C Consignor and it is not to be taken as amounting to a warranty or ②累積 ⑤再発給 representation of fact by the Designated Authority or its servants. The undersigned, duly authorised issed・日付 by the Designated Issuing Authority certifies on the basis of information supplied and to the少の非原産材料 best of his knowledge and belief that the goods designated above are of AUSTRALIAN origin, production or manufacture under the a （原則として船積みの時まで ③ provisions of the Australia trralia – Japan Economic Partnership Agreement. ⇒それより後の発給を及発給として扱う。）に該当する場合にチェックを入れる。 ③……………… COMPANY: …………………… ………………… それぞれ NAME OF AUTHORISED OFFICER ①NON PARTY INVOICE ②ACCUMULATION ③DE MINIMIS ④RETROSPECTIVE ⑤ DUPLICATION OF SIGNATURE OF AUTHORISED OFFICER ORIGINAL DATE ※前頁の様式に産品を全て記入できない場合に使用。 Continuation Sheet ORIGINAL CERTIFICATE No. HARMONIZED SYSTEM CODE (SIX DIGITS) PREFERENCE CRITERION DESCRIPTION OF GOODS: (WO, PE, PSR) 産品のHS番号（2012年版）原産地基準産品名（産品名、重量、数量等）・産品毎に HS６桁レベルで・産品毎に・産品名等の記載は産品の仕入書における品名とHS 関税分類を十のHS番号を記載しなけれ WO、PE、PSR 分関連付けられるようにする。の原産地基準をばならない。記載する。輸出者（又は代理人）による記入。空欄にはそれぞれ ①原産地証明書の枚数 ②輸出者(又は代理人)署名（自署又は電子的印刷） ③輸出者（又は代理人）の名称 ④輸出者管理ID を記入。 I certify that: - The information in this document is true and accurate and I assume the responsibility for proving such representations. I understand that I am liable for any ffalse statements or material omissions made on or in connection with this document. - I agree to maintain, and present upon request, documentation necessary to support this Certificate, and to inform, in writing, all persons to whom the C Certificate was given of any changes that would affect the accuracy or validity of this Certificate. - The goods originate in the territory to of one or both Parties and comply with the origin requirements specified for those goods in the Australia – Japan Economic on Partnership Agreement. ① pages, including all attachments. This Certificate consists of ______ ② SIGNED: ................................. EXPORTER REGISTRATION ID: ④ ……………… ③ COMPANY: …………………… This Certificate is based on the information supplied to the Designated Issuing Authority by the Consignor and it is not to be taken as amounting to a warranty or representation of fact by the Designated Authority or its servants. The undersigned, duly authorised by the Designated Issuing Authority certifies on the basis of information supplied and to the best of his knowledge and belief that the goods designated above are of AUSTRALIAN origin, production or manufacture under the provisions of the Australia – Japan Economic Partnership Agreement. (INTENTIONALLY BLANK SPACE) NAME OF AUTHORISED OFFICER 輸出締約国の権限ある当局又は発給機関による記入。・発給職員氏名・発給職員署名（自署又は電子的印刷）・日付（原則として船積みの時まで ⇒それより後の発給を及発給として扱う。） RE OF AUTHORISED AUTHOR SIGNATURE OFFICER DATE