EXPORT DECLARATION SUPPLEMENTARY PAGE
Approved Form paragraphs 114(3)(c) and 162AA(3)(a) of the Customs Act 1901
Complete one of these pages for each commodity
Page
of
Pages
1. Line No.
3. Commodity Classification
Code (AHECC)
2. Your Reference
3. Goods Description
5. Goods Origin Code
6. Temporary Import No.
7. Goods Origin Country Code
8. Net Quantity
a.) Amount
b.) Unit
9. Gross Weight
a.) Amount
b.) Unit
10. Line FOB Value:
11. Permit Details:
12. Assay Details:
a.) Assay Element
b.) Assay Concentration
c.) Assay Unit
Signature:
Date:
/
/
B957a (OCT 2015)