Division FORM FOR APPLICATION FOR A DEROGATION
| 1. Commercial description of the finished product 1.1 Customs classification (HS heading) | 2. Anticipated annual quantity of exports to the European Union (weight, number of pieces, metres or other unit) |
| 3. Commercial description of third country materials Customs classification (HS heading) | 4. Anticipated annual quantity of third country materials to be used |
| 5. Value of third country materials | 6. Ex-works value of finished product |
| 7. Origin of third country materials | 8. Reasons why the rule of origin for the finished product cannot be fulfilled |
| 9. Commercial description of materials originating in the countries or territories referred to in Article 7 to be used | 10. Anticipated annual quantity of materials originating in the countries or territories referred to in Article 7 to be used |
| 11. Value of materials of the countries or territories referred to in Article 7 to be used | 12. Working or processing carried out in the countries or territories referred to in Article 7 without obtaining origin |
| 13. Duration requested for derogation from … to… | 14. Detailed description of working or processing in Côte d'Ivoire |
| 15. Capital structure of the firm(s) concerned | 16. Amount of investments made/foreseen |
| 17. Staff employed/expected | 18. Value added by the working or processing in Côte d'Ivoire: 18.1 Labour: 18.2 Overheads: 18.3 Other: |
| 19. Other possible sources of supply for materials | 20. Possible developments to overcome the need for a derogation in the future |
| 21. Remarks |