別記第33号様式(2)(第三十四条関係)
　　日本　　　　　　　　　　　　　　　 Export Declaration No.　　　　　　　　
　　JAPAN　　　　　　　　　　　　　　　 Date of Issue:　　　　　　　　　　　　
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EXPORT DECLARATION
　In regardto the export of psychotropic substances Listed in Schedule Ⅲ of the 1971 Convention on Psychotropic Substances and／or preparations containing such psychotropic substances,
Name and Address of Exporter	
Name and Address of Importer	
In the case of the Substance
 International Non‐proprietary Name(INN) and Quantity	
In the case of Preparation containing the Substance
a．Pharmaceutical Form
b．INN and Contents of the Substance contained therein
c．The Quantity of such Preparation
d．The total Quantity of such Substance(b×c)	
Port of Exportation	
Date of Exportation	
　The undersigned hereby declares that above information, submitted on behalf of the exporter, is, to the best of his knowledge, complete and correct.
担当者名　　　　　　　　　　　　　
(Name of person in charge of Exporter)
　(注意)　用紙の大きさは、Ａ４とすること。