I
_______________________________________
(Shipper first &
last Name) of ______________ ____ __ _____
_____________________
(address)
___________________________
(city)
______________________
(state)
_______________
(zip),
Tel: _____________________________ hereby certify that I
purchased and or packed the contents of the said package/(s). I also
certify that these package/(s) do not contain dangerous goods and are
not fraudulently acquired. That I am Authorizing Impex Worldwide
Express to ship package/(s) to:
Receiver
First & last Name: ____________________________________________
Receiver Address:
_____________________________________________________
_________________
City:
___________________________ State:
_______________ Country:
________________________
Receiver
Tel: ___________________________
I certify under penalty of perjury & prosecution under the
laws of the United States of America that the information provided
above is true, correct & to the best of my knowledge.
Signed:
______________________________Date: _____/_____/_______