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Certificate of Origin Sample Form

This certificate of origin summarizes information for three products being exported from Canada to Vietnam. It certifies that product numbers 9300-0002 and 1000-0030 originated in Canada, while 1020-0002 originated in Canada but production information is unavailable. The certificate is signed by a spare parts coordinator and valid from January 1, 2021 through December 31, 2021.

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Adolf Nguyễn
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364 views1 page

Certificate of Origin Sample Form

This certificate of origin summarizes information for three products being exported from Canada to Vietnam. It certifies that product numbers 9300-0002 and 1000-0030 originated in Canada, while 1020-0002 originated in Canada but production information is unavailable. The certificate is signed by a spare parts coordinator and valid from January 1, 2021 through December 31, 2021.

Uploaded by

Adolf Nguyễn
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

CERTIFICATE OF ORIGIN

19 CFR 181.11, 181.22

OMB NO. 1651-0098

1. Exporter Name and Address: 2. Blanket Period (DD/MM/YY)

Fossil Power Systems Inc. FROM: 01/01/2021


10 Mosher Drive
Dartmouth, NS TO: 31/12/2021
B3B 1N5

Tax Identification Number: 121046718RT0001

3. Producer Name and Address: 4. Importer Name and Address:


Cong Ty Tnhh Vifutech (Vifutech Co., Ltd.)

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Available upon Request 85 Hoang Sa, DaKao Ward, District 01
Ho Chi Minh City
Viet Nam SR

at
5. 6. 7. 8. 9. 10.
Description of Good(s): H. S. Tariff Preference Producer Net Country of
Classification Criterion Cost Origin
Number
P/N: 9300-0002: Water Level Measuring Probes 9026.90.20.00 B Yes No CANADA

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P/N: 1000-0030: Port Cover Bolts 9026.90 B No(3) No CANADA
P/N: 1020-0002: Belleville Washers 7320.90 B No(3) No CANADA

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I certify that:

- THE INFORMATION ON THIS DOCUMENT IS TRUE AND ACCURATE AND I ASSUME THE RESPONSIBILITY FOR PROVING SUCH REPRESENTATIONS. I
UNDERSTAND THAT I AM LIABLE FOR ANY FALSE STATEMENTS OR MATERIAL OMISSIONS MADE ON OR IN CONNECTION WITH THIS DOCUMENT:
Sa

- I AGREE TO MAINTAIN, AND PRESENT UPON REQUEST, DOCUMENTATION NECESSARY TO SUPPORT THIS CERTIFICATE, AND TO INFORM, IN WRITING,
ALL PERSONS TO WHOM THE CERTIFICATE WAS GIVEN OF ANY CHANGES THAT COULD AFFECT THE ACCURACY OR VALIDITY OF THIS CERTIFICATE;

- THE GOODS ORIGINATED IN THE TERRITORY OF ONE OR MORE OF THE PARTIES, AND COMPLY WITH THE ORIGIN REQUIREMENTS SPECIFIED FOR
THOSE GOODS IN THE NORTH AMERICAN FREE TRADE AGREEMENT, AND UNLESS SPECIFICALLY EXEMPTED IN ARTICLE 411 OR ANNEX 401, THERE
HAS BEEN NO FURTHER PRODUCTION OR ANY OTHER OPERATION OUTSIDE THE TERRITORIES OF THE PARTIES; AND

- THIS CERTIFICATE CONSISTS OF ___1___ PAGES, INCLUDING ALL ATTACHMENTS.


11. AUTHORIZED SIGNATURE: COMPANY: Fossil Power Systems Inc.

NAME (PRINT OR TYPE): TITLE: Spare Parts Coordinator


Jody Pass
DATE: (DD/MM/YY): 08/04/2021 TELEPHONE: 902-468-2743 FAX: 902-468-2323

12/93 Customs Form 434


(12/17/93)

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