1. THE UNDERSIGNED - Name of the individual completing and signing the certificate (see Block 13); may be the Exporter or Agent of the Exporter.

2. FOR - The Company name and address of the Exporter (Distributor or Manufacturer) effecting the shipment of merchandise.

3. SHIPPED ON - Name of the vessel, aircraft, rail, or trucking company. May also include vessel number and flag, flight number and flag, rail car number, and truck Pro number.

4. DATE - The date the carrier left the port/terminal for the destination.

5. CONSIGNED TO - The Consignee, as it appears on the Commercial Invoice; may be "To Order of Shipper," or "To Order of (Customer's) Bank, or to any other entity, on the Conditions of Sale and/or the letter of credit.

6. MARKS AND NUMBERS - The marks recorded on each package, including Shipper's Company Name, Country of Origin (i.e. - Made in USA), Destination Port of Entry, and Customer's Company Name; may also include a Shipper's Control Number (i.e. - C/I No.) and the Customer's Import license Number. "Number" refers to the numbering of the packages in the shipment (i.e. - 1 of 30, 2 of 30, etc.).

7. NO. OF PACKAGES - The total number of packages, cartons, boxes, skids, etc. per description line, including outer packaging, in kilograms.

8. GROSS WEIGHT - Total weight of packages per description line, including outer packaging, in kilograms.

9. NET WEIGHT - Total weight of all packages per description line, excluding outer packaging, but including inner packaging, in kilograms.

10. DESCRIPTION - Full description of items being shipped, the type of containers, the gross weight per container, and the quantity and unit of measure of the merchandise. May also include cross references to Purchase Order or Commercial Invoice number.

11. SWORN BEFORE - Notary Republic seal/signature, and date notarized.

12. DATE - Date Certificate of Origin was prepared and signed.

13. SIGNATURE - The signature of the owner, employee, or agent appearing in Block 1 above.

14. CHAMBER OF COMMERCE - Name of local Chamber of Commerce (and State) certifying the origin of the merchandise.

15. SECRETARY - Authorized signature of the local Chamber of Commerce Secretary and that organization's seal.