Form TM-11 Export Certificate

FORM APPROVED

REPRODUCE LOCALLY. Include form number and date on all reproductions.

USDA

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
NATIONAL ORGANIC PROGRAM

-

OMB NO. 0581-0191

A knowingly false entry or false alteration of any entry on this certificate
may result in a fine of not more than $11,000 or imprisonment for not
more than five years or both (18 USC 1001) and may result in revocation
of accreditation under the National Organic Program (7 U.S.C. 6519).

EXPORT CERTIFICATE
I

COUNTRY OF DESTINATION

DATE

EXPORTED BY (Name and address including ZIP Code)

PRODUCT EXPORTED FROM

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CONSIGNED TO (Name and address including ZIP Code)

CERTIFYING AGENT ISSUING CERTIFICATE

TOTAL MARKED NET WEIGHT

TOTAL CONTAINERS
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PRODUCT AS LABELED

LOT NUMBER 1 1

ARKED
WEIGHT OF
LOT 1 1

NUMBER OF
PACKAGES IN
LOT 1 1

SHIPPING
MARKS

PRODUCER

I1 As sfafed by exporter
REMARKS

that the agricultural products specified hereon have been certified by a USDA accredited organic certifying agent and
have been found to meet all applicable requirements of the National Organic Program.
SIGNATURE OF ACCREDITED CERTIFYING AGENT

DATE

NOT VALID UNLESS SIGNED BY A DESIGNATED REPRESENTATIVE OF A USDA ACCREDITED ORGANIC CERTIFYING AGENT

No financial liability shall attach to the United States Department of Agriculture or to any officer or representative ofthe
Department with respect to this certificate.
According t o the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a coliection of information unless it displays a
valid OMB control number. The valid OMB control number for this information coliection is 0581-0191. The time required to complete this information collection is estimated to average
15 minutes per person, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information.  
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, coior, national origin, age, disability, and where applicable, sex,
marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual's income is derived from any public
assistance program (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape,
etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue,
S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

TM-11 (09-06)