（別記様式５－５）ブルネイ
Declaration for the import from Japan into Brunei Darussalam
② 整理番号を記載
① B/L ﾅﾝﾊﾞｰ、AWB ﾅﾝﾊﾞｰ、ｲﾝﾎﾞｲｽﾅﾝﾊﾞｰ等を記載
(証明書発給機関で記載)
Consignment/Invoice Number ............................... Declaration Number ....................................
③ 証明書発給機関名を記載 (証明書発給機関で記載)
例：○○ Regional Agricultural Administration Office, Ministry of Agriculture, Forestry and Fisheries
..................................................................................................................................................................
............................................................................................................................ (competent authority)
DECLARES that the food of this consignment composed
④ 具体的品目名、包装形態、重量等を記載
of: ...........................................................
.................................................................................................
（品目数が多い場合は「See Annex」等と記載し、各々を記載した別紙を添付）
............................................................................(description of consignment, product, number and
type of packages, gross or net weight) embarked
⑤ 日本の港名及び国名（例：□□ port, Japan）
at .........................................................................................................(embarkation
place)
⑥ 日本からの出国日を記載
on .....................................................................................................................
(date of embarkation)
⑦ 運送方法を記載（船便名、航空便名等）
by .........................................................................................................
(identification of transporter)
⑧ ブルネイの港名及び国名(例：■■ port, Brunei Darussalam)
going to .........................................................................................(place and country of destination)
⑨ 産地証明：福島県以外の４６都道府県産及び福島県産で下記表の指定された品目以外の場合、□にﾁｪｯｸ
（手書き or 左ﾀﾞﾌﾞﾙｸﾘｯｸで操作（規定値の設定をオン））複数の場合は、「See Annex」等と記載し、各々の情報を記載したリストを添付。
originates from the prefecture other than Fukushima, or originates from the prefecture of
Fukushima which don’t fall into designated items in the table below.
⑭
いずれか
ひとつを
チェック
⑩ 検査証明：福島県産で下記表の指定された品目の場合、□にﾁｪｯｸ（手書き or 左ﾀﾞﾌﾞﾙｸﾘｯｸで操作（規定値の設定をオン））
放射性検査報告書の添付が必要。複数の場合は、別添リストによる複数の証明は不可。
（放射性物質検査報告書の添付が必要。複数の場合、別添リストによる複数の証明は不可。）
originates
from the Fukushima which falls into designated item in the table below, and has been
検査サンプル採取日を記載
検査実施日を記載
sampled on⑪
................................
(date), subjected to laboratory analysis on.. ⑫
..............................(date)
⑬
検査機関名を記載 (複数の検査機関の場合は、「See Annex」等と記載)
in the .......................................................................................................................................(name of
laboratory) to determine the level of the radionuclide, caesium-134 and caesium-137. The analytical
report is attached.
Exporters (name, address, country)
⑮ 輸出者（名称、住所、国名）について記載
......................................................................................................................................................
Consignee (name, address, country)
⑯ 輸入者（名称、住所、国名）について記載
.............................................................................................................................................................
Date of issue: ⑰ 証明書発給年月日 (証明書発給機関で記載)
Signature:
⑱ 署名 (証明書発行機関で記載)
（例：農林太郎（代理者の場合、農水花子））
印
Name of authorised officer at competent authority:
⑲ 証明書発給権者の氏名 (証明書発給機関で記載)
(例：Taro Nourin (代理者である農水花子が署名する場合は、Hanako Nousui))
(Stamp of competent authority)
㉑ 証明書発給機関の印
(証明書発給機関で押印)
Designation:
⑳ 証明書発給権者の役職名 (証明書発給機関で記載)
例：Director of ○○ Regional Agricultural Administration
Office, Ministry of Agriculture, Forestry and Fisheries
(代理者が署名する場合は、For the Director General of ○○
Regional Agricultural Administration Office, Ministry of
Agriculture, Forestry and Fisheries)
Designated items
(verified by authority in Japan as well as Radioactive Substance Analysis Report)
Fruit and vegetables (fresh and processed), Tubers (including potatoes and sweet potatoes),
Seaweed, Green tea products originating from the prefecture of Fukushima
※Remark：Meats, seafoods, milk and dairy products originating from the
prefecture of Fukushima are suspended