Canadian Exporter
Name:
Company:
Street and No:
City:
Country/Territory:
Province/State:
Postal Code:

Consignee Name and Complete Address
Name:
Street and No:
City:
Country/Territory:
Province/State:
Postal Code:

Shipment Information
Business Number:	Left nine digits
RM Extension:	Right four digits
Exporter Reference Number:
Transport Document Number:
Date Of Export:
Country of Final Destination:
Export Permit Number:
Name of Exporting Carrier:
Vessel Name if Marine:
Currency of Declared Value:
Place of Exit:
Freight Charges to Point of Exit:
Mode of Transport from Point of Exit:	Road Rail Water Air Other
Other Mode of Transport (if applicable):
Conveyance Number:
Containerized:	Yes No
Reason for Export (if goods not sold):

If additional item space is necessary to complete this form, please enter the number below:
Number of additional items:

Description
Province of Origin	Country of Origin	Item Description	HS Commodity Code	Quantity	Quantity Unit Of Measure	Value F.O.B. Point of Exit

Gross Weight:	Pounds Kilograms
Package Count:
Package Type:
Package Container Number:

Service Provider Information
Name:
Street and No:
City:
Country/Territory:
Province/State:
Postal Code:
Telephone:	Digits only

Person Responsible for Completion
Name:
Company:
Street and No:
City:
Province/State:
Postal Code:
Telephone:	Digits only
Status:	Exporter Other