Completion Instructions
1. Provide the certifier's legal name, address (including country), telephone number, and an e-mail address.
2. Provide the exporter's name, address (including country), e-mail address, and telephone number if different from the certifier. This information is not required if the producer is completing the certification of origin and does not know the identity of the exporter. The address of the exporter shall be the place of export of the good in a party's territory.
3. Provide the producer's name, address (including country), e-mail address, and telephone number, if different from the certifier or exporter or, if there are multiple producers, state "Various" or provide a list of producers. A person that wishes for this information to remain confidential may state "Available upon request by the importing authorities". The address of a producer shall be the place of production of the good in a Party's territory.
4. Provide, if known, the importer's name, address, e-mail address, and telephone number. The address of the importer shall be in a party's territory.
5. Include the blanket period, if the certification covers multiple shipments of identical goods for a specified period of up to 12 months as set out in article 5.2 (Claims for Preferential Treatment).
6. Provide a full description of each good. The description should be sufficient to relate it to the invoice description and to the Harmonized System (HS) description of the good. If the certifiction covers a single shipment of a good, include the invoice number as shown on the commercial invoice. If not known, indicate another unique reference number, such as the shipping order number.
7. For each good described in Field 6, identify the HS Classification to the 6 - digit level.
8. For each field described in field 6, state which Origin Criteria (A through D) is applicable. The rules of origin are contained in Article 4.2. Note: In order to be entitled to preferential tariff treatment, each good must meet at least one of the criteria below.

ORIGIN Criteria
"A" Wholly obtained or produced entirely in the territory of one or more of the parties, as defined in Article 4.3 (Wholly Obtained or Produced Goods)
"B" Produced entirely in the territory of one or more of the parties using non-originating materials provided the good satisfies all applicable requirements of Annex 4-B (Product-Specific Rules of Origin)
"C" Produced entirely in the territory of one or more of the Parties exclusively from originating materials
"D" "Except for a good provided for in Chapter 61 to 63 of the Harmonized System:

(i) produced entirely in the territory of one or more of the parties;

one or more of the non-originating materials provided for as parts under the Harmonized System used in the production of the good cannot satisfy the requirements set out in Annex 4-B (Product-Specific Rules of Origin) because both the good and its materials are classified in the same subheading that is not subdivided into subheadings or, the good was imported into the territory of a party in an unassembled or a disassembled form but was classified as an assembled good persuant ot rule 2(a) of the general Rules of Interpretation of the Harmonized System; and

(iii) the regional value content of the good, determined in accordance with Article 4.5 (Regional Value Content), is not less than 60 percent if the transaction value method is used, or not less than 50 percent if the net cost method is used"
9. Identify the country of origin of the good (CA, US, MX)
10. Indicate whether the certifier is the exporter, producer or importer, in accordance with Article 5.2 (Claims for Preferential Treatment)
The certification must be signed and dated by the certifier and accompanied by the following statement.

The goods described in this document qualify as originating and the information contained in this document is true and accurate. I assume reponsibility for proving such representations and agree to maintain and present upon request or to make available during a verification visit, documentation necessary to support this certification.

If needed a continuation sheet is available HERE