Certificate of Origin

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;
• 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 411 or annex 401, there has been no further production or any other operation outside the territories of the parties; and

Number of pages this certificate consists of
(including all attachments):