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17.01.96 N 25
|1. Exporter (name, full address, | Original |2. No | | country) |+| | |3. Year |4. Product | | || || Export licence | |5. Consignee (Name, full address, || | country) |6. Country of|7. Country of | | | origin | destination| |+| |8. Place and date of shipment - |9. Supplementary details | | Means of transport | | || |10. Description of goods - |11. CN code|12. Quantity|13. FOB | | Manufacturer | | (1) |Value (2) | || |14. Certification by the competent authority | | | |15. Competent authority (name,|At _____________ on _____________| | full address, country) | | | | (Stamp) | | | | | | (Signature) |