Export Certificate (FRM-0176)

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Appendix III
Forms

Export Certificate
(Under the Food and Drugs Act^{Footnote *} - R.S.C. 1985, c. F-27)

The undersigned exporter hereby certifies that the (description of article) packaged and labelled as follows:

and marked in distinct overprinting with the word "Export"

1. is not manufactured for consumption in Canada,
2. is not sold for consumption in Canada, and
3. Packages and contents of such packages do not contravene any known requirements of the law of (Name of country or countries) to which it is or is about to be consigned.

Dated at , this day of

Canada:In the matter of an Export Certificate under the Food and Drugs Act,

Province of:

To Wit:

I, of the of in the of
do solemnly declare:

1. that I am the "Exporter" issuing the certificate above set out and have a knowledge of the matters and facts herein declared to by me,
   
   or
   
   I am of
   
   the "Exporter" issuing the certificate above set out and have a knowledge of the matters and facts herein declared to by me (describe position of declarant as the agent of the "Exporter" in care of a Corporation issuing the certificate),
   
   
2. that the information set out in the said certificate is true,
   
   
3. that all information relevant to the purpose of said certificate is set out herein and no information relevant thereto has been knowingly withheld.
   And I make this solemn declaration conscientiously believing it to be true, and knowing that it is of the same force and effect as it made under oath, and by virtue of The Canada Evidence Act.

Declared before me at this day of.

A commissioner for Taking Oaths