ORIGINALEXPORTER 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 INDUSTRYUGROUP

CERTIFICATE OF ORIGIN

Level 2, 441 Stt Kilda
KRoad
MELBOURNE VICTORIA
R
3004 AUSTRALIA
T: +61 (0)3 9867 0111
1 F: -61 (0)3 9867 0157

The Australian Chamber of Manufactures
anhas merged with the MTIA tous
form the AustralianIndustry GroupInvoice 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・産品毎に HS６桁レベルで ・産品毎に分関連付けられるようにする。
WO、PE、PSR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
rate①原産地証明書の枚数
and I assume the responsibility for proving such representations.
represI
understand that I am liable for any false statements or materialdocument.
omissionsmadeonorinconnection
withthisd②輸出者(又は代理人)署名（自署又は電子的印刷）- I agree to maintain, and present upon request,
est ddocumentationnecessary to support this Certificate, and tto inform, in③輸出者（又は代理人）の名称
writing, all persons to whom the Certificatee wasof any changes that would affect the accuracy or val
validity of thisw given
va④輸出者管理ID
Certificate.
を記入。
- The goods originate in the territory of one or bothothth Parties and comply with the origin requirements specified
specifspecifi 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遡及発給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 or⑤再発給
representation of fact by ②累積
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 tothe best of his knowledge and belief that the goods designated above are
AUSTRALIAN origin, production or manufacture under thea of（原則として船積みの時まで③僅少の非原産材料
provisions of the Australia
trralia – Japan Economic Partnership Agreement.
⇒それより後の発給を遡及発給として扱う。）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 OFFICER①NON PARTY INVOICE②ACCUMULATION③DE MINIMIS④RETROSPECTIVE⑤ DUPLICATION OF

SIGNATURE OF AUTHORISED OFFICERORIGINAL
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

ORIGINALCERTIFICATE No.
HARMONIZED SYSTEM CODE (SIX DIGITS)

PREFERENCE CRITERIONDESCRIPTION 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WO、PE、PSRのHS番号を記載しなけれ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, inwriting, all persons to whom the C
Certificate was given of any changes that would affect the accuracy or validity of thisCertificate.
- 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 EconomiconPartnership 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 orrepresentation of fact by the Designated Authority or its servants. The undersigned, duly authorised by the Designated Issuing Authority certifies on the basis ofinformation supplied and to the best of his knowledge and belief that the goods designated above are of AUSTRALIAN origin, production or manufacture under theprovisions 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遡及発給として扱う。）

RE OF AUTHORISEDAUTHOR
SIGNATURE
OFFICERDATE