To: the Ministry of Economy and Industry

Annex A Updated on December 29, 2013

Affidavit accompanying an application to obtain Official Standard approval according to the Second Addendum to the Free Import Order, 5772 – 2012, and its subsequent revisions from time to time

To: The Ministry of Economy and Industry (through the Standards Institution of Israel, the ______Laboratory)

Further to Application no. ______requesting an Official Standard approval, submitted to the Israel Standards Institution, and dated (dd/mm/yyyy) __ / __ /____ , and after having been warned that I must declare the truth and that if I do not I shall be liable to the penalties fixed by law, I hereby declare with respect to the shipment, the details of which appear below, as follows:

1. Details of the imported goods

Importer's details Supplier's details Customs broker's details

Importer's name: ______Supplier's name: ______Customs broker's name: ______Importer's address ______Customs broker's address: ______Supplier's address: ______Circle the appropriate no. & ______complete the data: ______1. Authorized operator no. ______

2. Business registration no. ______

3. Benevolent society no./ Non-profit Org. ______

4. Other ______

Country of Supplier's Bill of lading Ship/plane Port of entry Date of entry Import Invoice no. no. registration no. ______Country of Quantity& Customs Product Producer's Description Model origin / unit of code group* name production measure 1 2 3 4 * Product group no. – as assigned by the Standards Institution for this specific importation.

2. The goods conform to the type that underwent a type/prototype test at the Standards Institution of Israel as detailed below (with respect to goods in Group 2):

Standard no. according to Prototype/type Date of Description of goods (incl. which the test certificate prototype/type type) prototype/type no. approval was tested 1 2 3 4

3. The goods conform to the requirements of the standards that govern them as indicated below:

Standard number Conforms to Description of goods (incl. type) Conforms to standard excl. entire standard clause nos. 1 2 3 4

4. I undertake not to market these goods until I have labeled them according to the requirements of the Official Standard.

5. I hereby undertake not to market the goods until I have corrected all the existing deficiencies, as indicated above, and ensured that they conform to the requirements of the Official Standards governing them.

6. I hereby undertake to maintain a product file for the prototype, prepared according to the instructions of the Commissioner of Standardization and according to the product group to which it belongs according to this declaration, for a period of seven years from the date of the final release of the product type, and to allow the Commissioner and whomever he authorizes to act in this capacity, to consult the model's product file in the course of conducting an inspection according to the Standards Law.

7. I declare that I have read "Instructions of the Commissioner of Standardization – granting an approval of an Official Standard", according to the Second Addendum to the Free Import Order, 5772 – 2012, and its subsequent revisions from time to time as published on the Ministry of Economy and Industry internet location and appearing there on the day on which I signed this declaration. I understand their content and am aware of the consequences of not adhering to them, including: a) In the event that goods belonging to this shipment are found in the market and they are not the declared goods of this application, the Commissioner of Standardization or any person empowered by him may seize and withhold them until they have been tested for their degree of conformity to the requirements of the Official Standard. Under such circumstances, payment for the conformity assessment examination shall be my responsibility. b) In the event that goods belonging to this shipment are found in the market which do not conform to the requirements of an Official Standard and/or they are not the goods upon which I made this declaration, the Commissioner of Standardization may determine that I am not permitted to make use of the channel for release of goods on the basis of a declaration and for a period of up to one year from the date of the seizure of the goods, I may market them solely on the basis of the results of an examination by the Standards Institution of Israel as to their conformity to an Official Standard, similar to goods belonging to category 1. c) To the degree that it is found that the goods that I imported in this shipment do not conform to the requirements of the Official Standard, the Commissioner of Standardization may, in addition to all other authorizations granted him by the Standards Law 5713 – 1953, require me to recall them at my own expense in the manner and under the conditions that he shall determine. d) Given the goods are found under the conditions set out in (a) and (b) above, the Commissioner of Standardization may publish a Warning to the Public regarding a possibility that harm may come to public health or safety or to the quality of the environment.

8. In addition to the above, I am aware that on the basis of this declaration, I shall receive a confirmation of conformity to an Official Standard for the release of the goods from Customs for marketing and sale and to the degree that my declaration shall be found false, I shall be liable to the punishment set out in the law.

This is my name and signature, and the content of my declaration regarding this shipment of goods (supplier's invoice no. ______; bill of lading no. ______)

______Stamp of the company/importer Signature and position Date

Attorney Confirmation

Under paragraph 15 of the Evidence Ordinance (New Version), 5731 – 1971, I the undersigned ______, Advocate, registered in the Israel Bar Association with license number ______, of ______St., city of ______hereby confirm that on the ___ day of the month of ______, in the year ______, Mr./Ms. ______appeared before me and identified him/herself by means of Identity Card no. ______and signed this declaration after I had duly warned him/her that they are required to state the truth, and if they do not, would be subject to the punishments prescribed by law. He/she confirmed the truth and correctness of the above declaration and signed it in my presence.

______, Attorney ______Name Attorney's stamp and signature Date