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Name and Address: Blanket Period: DD MM YY from 3 4 Producer's Name and Address: MM YY Importer's Name and Address: 5 6 Description of Goods 10 DD to HS tariff classification number 7 8 Preference criterion 9 Producer Gross weight or other quantity 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.

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