Export Declaration Form – Fill Out and Use This PDF

DTI form

Republic of the Philippines

EXPORT DECLARATION

Department of Trade and Industry

2 Exporter

TIN

Office of the Declaration

Declaration

Export Declaration Number

Date

BOI

PEZA

CLARK

SUBIC

OTHERS (pls. specify) _________

8 Importer/Consignee Address

5 No. of Item

6 Total Packages

3 Page

of

15 Province of Origin

17 Country of Destination

14 Declarant Address

TIN

18 Vessel / Aircraft

21 Local Carrier (If any)

28 Financial and Banking Data

27 Port and Date of Loading

29 Port and Date of Departure

Mode of payment : _____________ Bank Name : _______________

Terms of Payment :

with FOREX

without FOREX

Currency

22 Total FOB Value (Coffee only)

31

33 Harmonized System (HS) Code

35 Gross Weight (Coffee only)

Marks

and

Numbers

Container

KG

No(s).

37 Customs Procedure Code

38 Net Weight (Coffee only)

Number

And Kind

Descrip-

Tion of

KG

Goods

40 Previous Import Document No(s).

42 Supplementary Units

42 Item FOB Price

46 FOB Value of Imported Raw Materials

44

Addt’l

Infos /

Doc

Produced

Cert. &

Auth.

50 We hereby certify that documents and information produced and provided herewith

52 Bureau of Customs (BOC) control

Are to the best of our knowledge and belief true and correct.

___________________________________________________________________________

_____________________________________________

____________________________________

Printed Name and Signature of Declarant

Printed name Signature

Position

Place and Date :

_______________________________________________

Date : ______________________________

51 AUTHORIZATION (a)

51 AUTHORIZATION

(b)

Name of Agency : _________________________

INTERNATIONAL COFFEE ORGANIZATION CERTIFYING AGENCY

COFFEE EXPORT CLEARANCE

_________________________________________________

_________________________________

CEC NUMBER

Printed name / Signature

Position

___________________

_______________________________________

___________________________________________

ICO MARK

123 / ____ / _____

Date

Valid Unti;

ISSUANCE DATE

_______________

AUTHORIZED SIGNATORY

DTI / ICOCA - EMD

VALIDITY DATE

_______________