Part I : Details of dispatched consignment

I.1. Consignor

Name

Address

Postal code

Tel.

I.2. Certificate reference No

I.2.a.

I.3.

I.4.

I.5. Consignee

Name

Address

Postal code

Tel.

I.6.

I.7. Country of origin

ISO code

I.8.

I.9. Country of destination

ISO code

I.10.

I.11. Place of origin

Name

Approval number

I.12.

I.13.

I.14.

I.15.

I.16. Entry BIP in EU

I.17.

I.18.

I.19. Commodity code (HS code)

I.20. Quantity

I.21.

I.22. Number of packages

I.23.

I.24. Type of packaging

I.25. Commodities certified for:

Human consumption

I.26.

I.27. For import or admission into EU

I.28. Identification of the commodities

Species

(Scientific name)

Number of packages

Net weight

Part II: Certification

COUNTRY

Fishery products

I.(bis) Other information

Fishing area(s):

IMO/Lloyd's number (if issued) or call sign of the vessel:

Fishing Period:

Start date: …/…/…

Stop date: …/…/…

II. Health attestation

II.a. Certificate reference number

II.b.

II.1. Public health attestation

I, the undersigned, declare that

the vessel appears on the list of vessels from which imports to the European Union are permitted (being “EU-listed”);

the vessel has a programme based on the HACCP principles in order to control hazards;

the part of the vessel where fishery products are handled, equipment, containers and the cold storage for fishery products are kept clean and maintained in good repair and condition;

the fishery products have been protected from contamination and from the effects of the sun or any other source of heat as soon as possible after they have been taken on board, and that they have been handled in a way that prevents bruising and other damage;

the fishery products have not been contaminated by fuel, bilge water or pests;

the slaughter, bleeding, heading, gutting, removing fins, have been carried out hygienically as soon as possible after capture, and the products have been washed immediately and thoroughly. Viscera and parts that may constitute a danger to public health has been removed as soon as possible and kept apart from products intended for human consumption;

only clean seawater has been used as alternative to potable water for the handling and washing of the fishery product;

the fishery products have been subjected to a visual examination for the purpose of detecting visible parasites, and fishery products that are obviously contaminated with parasites are not placed on the market for human consumption;

freezing has been carried out hygienically as soon as possible after capture;

frozen fishery products have been kept at a temperature of not more than – 18 °C in all parts of the product, except whole fish initially frozen in brine intended for the manufacture of canned food may be kept at a temperature of not more than – 9 °C;

frozen blocks have been hygienically and adequately wrapped before landing;

the packages have been marked with an identification mark indicating the approval number of the freezer vessel and the flag state;

the wrapping material is not a source of contamination and has been stored in such a manner that it has not been exposed to a risk of contamination.

Notes part I:

Box reference I.1: Name and address (street, town and region/province/state, as applicable), telephone and fax numbers or the e-mail address of the owner of/ the responsible for the vessel.

Box reference I.2: A unique document number according to your own classification.

Box reference I.5:

The name and address (street, town and post code) of

the physical or legal person to whom the consignment is imported directly to the Member State of destination.

COUNTRY

Fishery products

Box reference I.7: The country of which the vessel issuing this document is flying the flag.

Box reference I.11: The name of the freezer vessel and approval number as listed in accordance with Article 12 of Regulation (EC) No 854/2004 from which the fishery products are imported directly.

Box reference I.19: Use the appropriate harmonised system (HS) code of the World Customs Organisation under the chapter 03.03.

Box reference I.20: Total net weight in kilo as sum from I.28.

Box reference I.22: Sum from I.28.

Box reference I.25: Tick the box “Human consumption”.

Box reference I.27: Tick the box if final destination is EU.

Box reference I.28: List the various species with scientific name, number of packages and net weight.

Captain of the freezer vessel

Name (in capital letters):

Date:

Signature:

Stamp:’