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Dress: B 2. Blanket period: Fax: From: E-Mail: To: (yyyy-mm-dd) (yyyy-mm-dd) Reference No.: 3. Producer's name and address: Telephone: 4. Importer's name and address: Fax: E-Mail: Telephone: Fax: E-Mail: Reference No.: 5. Description of Good(s) 6. HS Tariff Classification # 7. Preference Criterion 8. Producer 9. Value Test 10. Country of Origin I certify that: - The information in this document is true and accurate and I assume the responsibility for proving such representa.

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