1. No category

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