Name of the certificate holder:
Certificate number/firm number:
Product name and status: Net weight, gross weight, lot number:	, ,
Year of production / harvest of the product:
Product origin - last processor:
TC-Certificate Shipment as:	Digital PDF form - stamped and signed Paper form - stamped and signed
If paper form required, shipping to:	Company name Contact person Address Postal Code, City Country
Postal dispatch - without tracking option: Courier shipment by Kiwa BCS: Cost absorption courier by:	Yes No Yes No
Courier dispatch with your courier Your courier Your customer number	Yes No
The certificate should be created: Please note our price scale	within 5 working days - standard service within 2 working days – express service
Cost absorption certificate creation by

I have truthfully completed all requested information and have included the following attachments:

Invoice number

Transport document

If not available, to be submitted by

If required: Purchase Invoice and Certificate / Transaction Certificate supplier

_____________________________	_______________________________________________

Date	Stamp / name and signature of the applicant