FORM 1

       APPLICATION FOR KIMBERLEY CERTIFICATE

                                   [Section 2]

Name and address of applicant exporter/company

Name and address of applicant where not the exporter Name and address of consignee of rough diamonds Origin of rough diamonds

Longitude and latitude of exploration site

Place and name of the facility where diamonds extracted

Place and name of the mine

Mass of rough diamonds measured in carats

Value of rough diamonds in U.S. Dollars or the cedi equivalent

Thereby declared that the information contained in this application is correct.

Date Name Signature

FORM 2

FORM OF KIMBERLEY CERTIFICATE

[Section 3]

Name and address of exporter/company

Name and address of consignee

Mass of rough diamonds measured in carats

Value of rough diamonds in U.S. Dollars or the cedi equivalent

Harmonised System for the rough diamonds Number of containers in shipment

Serial number for each container

Date of issue and expiry of certificate

The rough diamonds in this shipment have been handled in accordance with the provisions of the Kimberly Process International Certificate Scheme for rough diamonds.

Date    Minister responsible for Mines

FORM 3

EXPORT REPORT FOR ROUGH DIAMONDS

[Section 4]

Name and address of exporter Name and address of consignee

Serial number of Kimberley Certificate

Date of export of rough diamonds

I hereby attest to the accuracy of the contents of this report

The rough diamonds in this shipment have been handled in accordance with the provisions of the Kimberley Process International Certificate Scheme for rough diamonds.

Date Name Signature

Note:   This report shall be authenticated by a customs officer at the time of expiration of the rough

diamonds and the duplicate of a report shall be given to the customs officer at the time of exportation of the rough diamonds.

FORM 4

REPORT ON IMPORT OF ROUGH DIAMONDS

[Section 5]

Name and address of importer

Name and address of consignee

Serial number of Kimberley Certificate Date of import of rough diamonds

I hereby attest to the accuracy of the contents of this report

Date Name Signature

Note:   This report shall be authenticated by a customs officer at the time of clearance of the rough

diamonds and the duplicate of the report shall be given to the customs officer at the time of clearance of the rough diamonds.