11f.
TELEPHONE
NUMBER

 THE INFORMATION ON THIS DOCUMENT IS TRUE AND ACCURATE AND I ASSUME THE RESPONSIBILITY FOR PROVING SUCH REPRESENTATIONS.  I UNDERSTAND THAT I AM LIABLE FOR ANY FALSE STATEMENTS OR MATERIAL OMISSIONS MADE ON OR IN CONNECTION WITH THIS DOCUMENT;

 THE GOODS ORIGINATED IN THE TERRITORY OF ONE OR MORE OF THE PARTIES, AND COMPLY WITH THE ORIGIN REQUIREMENTS SPECIFIED FOR THOSE GOODS IN THE NORTH AMERICAN FREE TRADE AGREEMENT AND UNLESS SPECIFICALLY EXEMPTED IN ARTICLE 411 OR ANNEX 401, THERE HAS BEEN NO FURTHER PRODUCTION OR ANY OTHER OPERATION OUTSIDE THE TERRITORIES OF THE PARTIES; AND

11.

OMB No. 1651-0098
See back of form for Paper-
work Reduction Act Notice.

NORTH AMERICAN FREE TRADE AGREEMENT

TAX IDENTIFICATION NUMBER:

4. IMPORTER NAME AND ADDRESS

2. BLANKET PERIOD

TAX IDENTIFICATION NUMBER:

3. PRODUCER NAME AND ADDRESS

TAX IDENTIFICATION NUMBER:

1. EXPORTER NAME AND ADDRESS

19 CFR 181.11, 181.22

Please print or type

FROM

TO

9.
NET COST

8.
PRODUCER

5.
DESCRIPTION OF GOOD(S)

7.
PREFERENCE
CRITERION

10.
COUNTRY
OF ORIGIN

11d. TITLE

11b. COMPANY

11a.  AUTHORIZED SIGNATURE

11c. NAME (Print or Type)

(Voice)

(Facsimile)

PAGES, INCLUDING ALL ATTACHMENTS.

 THIS CERTIFICATE CONSISTS OF

I CERTIFY THAT:

(country code, if applicable)

(country code, if applicable)

   I AGREE TO MAINTAIN AND PRESENT UPON REQUEST,  DOCUMENTATION NECESSARY TO SUPPORT THIS CERTIFICATE, AND TO INFORM, IN WRITING, ALL PERSONS TO WHOM THE CERTIFICATE WAS GIVEN OF ANY CHANGES THAT COULD AFFECT THE ACCURACY  OR VALIDITY OF THIS CERTIFICATE;

(MM/DD/YYYY)

Any data typed after screen scrolls will not print.

11e. DATE (MM/DD/YYYY)

CERTIFICATE OF ORIGIN

(This is a mandatory field.)

U S DEPARTMENT OF HOMELAND SECURITY Bureau of Customs and Border Protection NORTH AMERICAN FREE TRADE AGREEMENT CERTIFICATE OF ORIGIN Please print or type O M B Number 16 51-0098. See back of form for Paperwork Reduction Act Notice. Any data typed after screen scrolls will not print. I CERTIFY THAT THE INFORMATION ON THIS DOCUMENT IS TRUE AND ACCURATE AND I ASSUME THE RESPONSIBILITY FOR PROVING SUCH REPRESENTATIONS. I UNDERSTAND THAT I AM LIABLE FOR ANY FALSE STATEMENTS OR MATERIAL OMISSIONS MADE ON OR IN CONNECTION WITH THIS DOCUMENT; I AGREE TO MAINTAIN AND PRESENT UPON REQUEST, DOCUMENTATION NECESSARY TO SUPPORT THIS CERTIFICATE, AND TO INFORM, IN WRITING, ALL PERSONS TO WHOM THE CERTIFICATE WAS GIVEN OF ANY CHANGES THAT COULD AFFECT THE ACCURACY OR VALIDITY OF THIS CERTIFICATE; THE GOODS ORIGINATED IN THE TERRITORY OF ONE OR MORE OF THE PARTIES, AND COMPLY WITH THE ORIGIN REQUIREMENTS SPECIFIED FOR THOSE GOODS IN THE NORTH AMERICAN FREE TRADE AGREEMENT AND UNLESS SPECIFICALLY EXEMPTED IN ARTICLE 411 OR ANNEX 401, THERE HAS BEEN NO FURTHER PRODUCTION OR ANY OTHER OPERATION OUTSIDE THE TERRITORIES OF THE PARTIES; AND THIS CERTIFICATE CONSISTS OF INCLUDING ALL ATTACHMENTS Eleven

Form Page
1 of 1

Form Page 1 of 1

Printing requires Adobe Acrobat Reader.

Printing requires Adobe Acrobat Reader.

(This is a mandatory field)

U.S. DEPARTMENT OF HOMELAND SECURITY 
Bureau of Customs and Border Protection

CBP Form 434 (04/97)

C B P Form 434 (04/97) 19 CFR 181.11, 181.22

6.
HS TARIFF
CLASSIFICATION
NUMBER