"Certificate of Origin Form" - Canada

This fillable "Certificate of Origin Form" is a document issued by the Canadian Food Inspection Agency specifically for Canada residents.

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Certificate of Origin
To: The Canadian Food Inspection Agency
A Certificate of Origin is required in order to export material to Canada that is regulated for light brown apple moth
(LBAM)* and that was produced in a county of California that Canada does not regulate for LBAM. Appendix 2 of
D-07-03 lists the California counties that are regulated by Canada for LBAM.
•
The Certificate of Origin must be filled out completely. Any shipment accompanied by a Certificate of Origin
that is not completed correctly may be refused entry into Canada.
•
If a shipment includes commodities from several counties, each county must be listed on a separate certificate.
•
A single Certificate of Origin must be completed for each different commodity within a shipment.
* Carrots with tops removed, radishes with tops removed as well as highly processed vegetables and highly processed
fruit (chopped, sliced, peeled, etc.) are exempt from the requirements for light brown apple moth. Refer to Import
Directive D-07-03.
The products described below are produced in the California county of:
______________________________________ in an area where light brown apple moth (Epiphyas
postvittana), is known not to occur.
Exporter’s Name: __________________________________________________________
Exporter’s Address:
Street Address: _____________________________________________________________
City/ Town:
____________________________________________________________
State:
______________________
Zip Code: ________
Product Description:
Scientific (Botanical) Name: ___________________________________________________
Common Name: ____________________________________________________________
Quantity (weight, # of lots, etc.)**: _______________________________________________
Document reference (bill of landing #, airway bill #, invoice # , Canada Customs Invoice #, etc.)**:
__________________________________________________________________________
** Information provided must be sufficient to show that the commodity referred to on this certificate of origin
corresponds directly to that shown on import documents.
By signing this Certificate of Origin, the above named exporter certifies that the material described above
was produced in a California county in which light brown apple moth is known not to occur.
_____________________________
________________________________
Name of exporter (printed)
Signature of exporter
________________
Date (yyyy/mm/dd)
Certificate of Origin
To: The Canadian Food Inspection Agency
A Certificate of Origin is required in order to export material to Canada that is regulated for light brown apple moth
(LBAM)* and that was produced in a county of California that Canada does not regulate for LBAM. Appendix 2 of
D-07-03 lists the California counties that are regulated by Canada for LBAM.
•
The Certificate of Origin must be filled out completely. Any shipment accompanied by a Certificate of Origin
that is not completed correctly may be refused entry into Canada.
•
If a shipment includes commodities from several counties, each county must be listed on a separate certificate.
•
A single Certificate of Origin must be completed for each different commodity within a shipment.
* Carrots with tops removed, radishes with tops removed as well as highly processed vegetables and highly processed
fruit (chopped, sliced, peeled, etc.) are exempt from the requirements for light brown apple moth. Refer to Import
Directive D-07-03.
The products described below are produced in the California county of:
______________________________________ in an area where light brown apple moth (Epiphyas
postvittana), is known not to occur.
Exporter’s Name: __________________________________________________________
Exporter’s Address:
Street Address: _____________________________________________________________
City/ Town:
____________________________________________________________
State:
______________________
Zip Code: ________
Product Description:
Scientific (Botanical) Name: ___________________________________________________
Common Name: ____________________________________________________________
Quantity (weight, # of lots, etc.)**: _______________________________________________
Document reference (bill of landing #, airway bill #, invoice # , Canada Customs Invoice #, etc.)**:
__________________________________________________________________________
** Information provided must be sufficient to show that the commodity referred to on this certificate of origin
corresponds directly to that shown on import documents.
By signing this Certificate of Origin, the above named exporter certifies that the material described above
was produced in a California county in which light brown apple moth is known not to occur.
_____________________________
________________________________
Name of exporter (printed)
Signature of exporter
________________
Date (yyyy/mm/dd)
Canadian Food Inspection Agency Certificate of Origin Form Certificate Templates Canadian Federal Legal Forms Canada Legal Forms

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