Shipper:		Bill Number :
Company Name:
Address:
Contact Name:
Phone/Fax:
Consignee:
Company Name:		No. of pieces:
Address:
City:
State/Country:
Contact name:
Phone/Fax:

I declare that the information is true and correct to the best of my knowledge, and that the goods are of origin.

I (name) certify that the contents of this shipment are as stated above.