(別記様式２－１)

Declaration for the import into …………… (name of country or region)

………… Products from Japan

Invoice Number…………………… Declaration Number ..........................................................

.................................................................................................................................................................. ...............................................................................................................................(competent authority ) DECLARES that the ........................................................ (products ) of this consignment composed of: .................................................................................................................................................................. ..................... (description of consignment, product, number and type of packages, gross or net weight) embarked at .............................................................................................................. (embarkation place) on …………………………………………………………………… ……..(date of embarkation) by ................................................................................................................ (identification of transporter) going to ............................................................................................... (place and country of destination) which comes from the establishment ....................................................................................................... ........................................................................................................ (name and address of establishment)

is originating from a prefecture of …………………

(date) in the ......................................... (name of laboratory), to determine the level of the radionuclides, iodine-131, caesium-134 and caesium-137. Analytical report is attached.

Exporter (name, address, country) ................................................................................................................................................................. Consignee (name, address, country) ..................................................................................................................................................................

Done at ............................................... on .................................................................................................

authorised representative of competent authority

ｲﾝﾎﾞｲｽﾅﾝﾊﾞｰを記載 整理番号を記載 (証明書発給機関で記載)

証明書発給機関名を記載

例：FISHERIES AGENCY MINISTRY OF AGRICULTURE, FORESTRY AND FISHERIES, GOVERNMENT OF JAPAN

具体的な品目名、包装形態、重量等を記載 (品目数が多い場合は「See Annex」等と記載し、各々を記載したリストを添付。

日本の出港地を記載

日本からの出国日を記載

運送方法を記載（船便名、航空便名等）

到着港及び輸出先国・地域を記載

どちらかひとつを ﾁｪｯｸ

産地となる都道府県名を記載（複数の場合は「See Annex」等と記載し、各々の情報を記載したリストを添付）

検査サンプル採取日を記載

⑯ 検査機関名を記載

輸出者（名称、住所、国名）について記載

輸入者（名称、住所、国名）について記載

証明書発給年月日を記載 (証明書発給機関で記載)

例：○○ Apr. 2012(証明書発給機関で記載)

例：Director of Fisheries Processing Industries and Marketing Division Fisheries Agency The Government of Japan

印 農林 太郎

食品の場合は「food」、飼料の場合は「feed」と記載

輸出先国・地域を記載①

②

③ ④

⑤

⑥

⑧

⑨

⑩

⑪

⑬⑰

⑱

⑲

⑳ 証明書発給権者の役職名を記載し、押印・署名

食品は「food」と、飼料は「feed」と記載

⑦

has been sampled on ............... (date), subjected to laboratory analysis on .........................

検査実施日を記載⑮

㉑

⑫生産地又は加工施設の名称・所在地を記載。 ………………………………………………………………………………………….(name and address of establishment)

(生産地等が複数の場合は「See Annex」等と記載し、各々の情報を記載したリストを添付。）

⑭