MOVEMENT CERTIFICATE

1 Exporter (Name, full address, country)

EUR 1 NO. А 91Б921
See notes overleaf before completing this form

2 Certificate used in preferential trade between

THE EUROPEAN ECONOMIC COMMUNITY
3 Consignee (Name, full address, country) (Optional)
and

(Insert appropriate countries, groups of countries or territories)

4 Country, group of countries or 5 Country, group of countries or

territory in which the products territory of destination
are considered as originating

6 Transport details (Optional) 7 Remarks

8 Item number*; marks and numbers Number and kind of packages (1); description of goods 9 Gross weight (kg) 10 Invoices
or other measure (optional)
(litres, cu.m, etc.)

11 CUSTOMS ENDORSEMENT 12 DECLARATION BY THE EXPORTER

Export document (2): Stamp
I, the undersigned, declare that the goods
Form
described above meet the conditions
No required for the issue of this certificate

Customs office

ЙГ IRELAND (Place and Date)

Declaration certified in order
Date

(Signature) (Signature)

See note 2 overleaf R.C.S.B. C. & E.No. 964

13 REQUEST FOR VERIFICATION, to:- 14 RESULT OF VERIFICATION

The Secretary, Verification carried out shows that this certificate (1)
Office of the Revenue Commissioners,
Government Offices, [ I was issued by the Customs Office indicated
Nenagh, I ' and that the information contained therein
Co. Tipperary, is accurate.
Ireland.

I I does not meet the requirements as to authenticity

Verification of the authenticity and accuracy of ' ' and accuracy (see remarks appended).
this certificate is requested.

(Place and Date) (Place and date)

(Signature) (Signature)

Stamp Stamp

(1) Insert X in the

appropriate box.

NOTES

1. Certificates must not contain erasures or words written over one another. Any alterations must be made by deleting
the incorrect particulars and adding any necessary corrections. Any such alteration must be initialled by the person
who completed the certificate and endorsed by the Customs authorities of the issuing country or territory. Where
certificates are completed in handwriting, they must be written in ink in printscript.

2. No spaces must be left between the items entered on the certificate and each item must be preceded by an item
number. A horizontal line must be drawn immediately below the last item. Any unused space must be struck through
in such a manner as to make any later additions impossible.

3. Goods must be described in accordance with commercial practice and with sufficient detail to enable them to be
identified.

2
 APPLICATION FOR A MOVEMENT CERTIFICATE
1 Exporter (Name, full address, country)
EUR 1 NO. A 916921
See notes overleaf before completing this form

2 Certificate used in preferential trade between

THE EUROPEAN ECONOMIC COMMUNITY
3 Consignee (Name, full address, country) (Optional)
and

(Insert appropriate countries, groups of countries or territories)

4 Country, group of countries or 5 Country, group of countries or

territory in which the products territory of destination
are considered as originating

6 Transport details (Optional) 7 Remarks

8 Item number*; marks and numbers Number and kind of packages (1); description of goods 9 Gross weight (kg) 10 Invoices
or other measure (optional)
(litres, cu.m, etc.)

11 CUSTOMS ENDORSEMENT 12 DECLARATION BY THE EXPORTER

Export document (2): Stamp
I, the undersigned, declare that the goods
Form
described above meet the conditions
No required for the issue of this certificate

Customs office
Issuing country
or territory; (Place and Date)
Declaration certified in order
Date

(Signature) (Signature)

* See note 2 overleaf R.C.S.B. C. & E.No. 964

 APPLICATION FORM FOR MOVEMENT CERTIFICATE (TO BE RETAINED BY CUSTOMS)
DECLARATION BY THE EXPORTER

I, the undersigned, exporter of the goods described overleaf,

1. DECLARE that these goods originated in (1)
in accordance with the definition of originating products contained in the Agreement mentioned in Box
2 overleaf and that they meet the conditions required for the issue of the attached movement certificate. (2)

2. SPECIFY as follows the circumstances which have enabled these goods to meet the above conditions (3):

3. SUBMIT the following supporting documents (4):

4. UNDERTAKE to submit, at the request of an officer of Customs and Excise, any supporting evidence which the officer
may require for the purpose of issuing the attached certificate, and undertake, if required, to agree to any
inspection of my accounts and to any check on the processes of manufacture of the above goods, carried out
by the said officer of Customs and Excise:

5. REQUEST the issue of the attached movement certificate for these goods.

6. DECLARE that I am familiar with and understand the rules of origin which apply to the goods covered by this certificate.

(Signature of exporter) (Place and date of signature)

(1) Insert "the Community", or the name of the agreement country (e.g. Chile), or group of countries (e.g. EFTA), in which the
goods are deemed to originate.

(2) The conditions required for the issue of the attached certificate are specified in the relevant Protocol concerning the definition
of originating products annexed to the Agreement between the EEC and the country or territory named in box 2 overleaf.

(3) List the products used in the process of manufacture, their tariff headings and their country of origin, together with the name
and tariff heading of the goods obtained. A short statement should be added indicating why the goods are deemed to have
acquired originating status, e.g. "I declare that these goods have satisfied the origin conditions: by a change of tariff heading,
or by satisfying the relevant rule, or because they were wholly produced in the territory referred to above" (use only the
appropriate phrase). In certain cases, the exporter may be required, in addition, to indicate the values of the products used
and the value of the finished product.

(4) For example: copies of the import documents, movement certificates, certificates of origin, manufacturer's invoices, supplier's
declarations, etc., referring to the products used in manufacture or the goods re-exported in the same state.

PENALTIES FOR FURNISHING FALSE INFORMATION

The Irish Customs may, at any time, either at their own discretion or at the request of the Customs of the
importing country, take steps to verify statements made on movement certificates. Any person who supplies
false information or evidence, etc., to Customs in support of an application for the issue of a movement
certificate or in the course of any subsequent verification may be liable to severe penalties. Exporters are
strongly advised in their own interests to read carefully the relevant Customs Notices referred to above
before making any declaration on movement certificates or application forms.