Annex I - C-PIQ establishment transfer document

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(Between C-PIQ establishments, for shipments of potatoes intended to be exported to the United States)

Tracking No. space

C-PIQ Establishment space

C-PIQ Registration No. space

C-PIQ Establishment address space

Shipper space

Receiving C-PIQ establishment (Name and address) space

Product description
Marks on packages:
No. Product/Type/Variety Number and type of pkgs. Grade Size Lot ID

Date product packed/monitored: space

The product described above originates in the province of space

I hereby warrant and certify that I have the authority to sign this C-PIQ Establishment Transfer Document on behalf of the C-PIQ establishment registered above.

I hereby do warrant and certify that all the information contained on and in this document is fully true and accurate and that the product described above was prepared in and shipped from a facility operating under the C-PIQ program.

I understand and acknowledge that if any information set out herein is found to be false, misleading or deceptive, this may result in enforcement action by CFIA.

Name of establishment signatory space

Signature spaceDate space