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 N^o.

C-PIQ Establishment

C-PIQ Registration N^o.

C-PIQ Establishment address

Shipper

Receiving C-PIQ establishment (Name and address)

Date product packed/monitored:

The product described above originates in the province of

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

Signature Date