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|Грузоотправитель (экспортер)    |Дата, справочный номер и т.д.  |

|                                |                               |

|--------------------------------|-------------------------------|

|Грузополучатель                 |Покупатель (если он не         |

|                                |грузополучатель) или другой    |

|                                |адрес                          |

|--------------------------------|-------------------------------|

|Адрес для уведомления или       |Страна отправления             |

|доставки                        |-------------------------------|

|                                |Страна          |Страна        |

|                                |происхождения   |назначения    |

|--------------------------------|-------------------------------|

|Сведения относительно           |Условия поставки и платежа     |

|транспортировки                 |                               |

|                                |                               |

|--------------------------------|-------------------------------|

|Отгрузочная    |Количество и род|Товарный | Вес      |Объем     |

|маркировка;    |грузовых мест;  |номер    | брутто   |          |

|номер          |описание товара |         |          |          |

|контейнера     |                |         |          |          |

|                                |         |          |          |

|                                |         |----------|----------|

|                                |         |Количество|Стоимость |

|                                |         |нетто     |          |

|                                |         |          |          |

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|  ПОЛЕ СВОБОДНОГО ИСПОЛЬЗОВАНИЯ                                 |

|                                                                |

|                                                                |

|                                                                |

|                                                                |

|                                                                |

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|                                |Место и дата составления;      |

|                                |удостоверение подлинности      |

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