Original
'1. Products consigned from (Exporter's business name, address, Reference No. gzotozgtz3?(i084l (pAffj 1 0F z)
country)
YIWI' GODI,TM TRAI]I' (0. ,I,TT] ASEAN.CHINA FREE TRADE AREA
IiOOM t)0 1, YT*IAI INTERMTIONAL I]I J I II]IN6, NO l 37?
PREFERENTIAL TARIFF
GIOIIZHOU NORITI ROAI} CKNJ$MNG SMNET YIWU ZI{B.IIAN6
CIIINA CERTIFICATE OF ORIGIN
(Combined Declaration and Certificate)
2. Products consigned to (Consignee's name, address, country)
Pl'TURYA CIP]A NIAG{I'AMA
FORM
J,.fdlM. l'{AMtUIl N0. 217, I'rtil.. JEM',ATAN l.IM{ KIi(:.
1'AM[i0&q,K01A ADM JAr\ARTA BAI{AT"PIt0P. Dl(I .IAIURTA
lssued in THE PEOPLE'S REPUBLIC OF CHINA
II\D0NH:IIA PIl0Mt 0?1*6i13(i20li (Country)
IiAX:021- 6336203 NPWP llL 200 ii15 0*0:ii].000
See Overleaf Notes
-
3. Means of transport and route (as far as known) 4. For Official Use 'r
Verri f icat i r:n : ori g:i.rr. cus t,url:i. gov. otl
Departure date AI"'R' 30' 2020 E Preferential Treatment Given
flvli]K B00MY 0i62-0??s
Vessel's name / Aircraft etc.
E Preferential Treatment Not Given (Please state reason/s)
Port of Discharge illil'iARANG, IN|$MjSIA
IIR0M ](IAli{iil{, GIINA T0 :frMA}ilNG. INDONES]A BY SE
Signature of Authorised Signatory of the lmporting Party
5. ltem 6. Marks and 7. Number and type of packages, description 8. Origin criteria 9. Gross weight or net 10. Number,
Number numbers on of products (including quantity where (see Overleaf weight or other quantity, date of
packages appropriate and HS number in six digit code) Notes) and value (FOB) only lnvoices
when RVC criterion is
applied
I N/M STVSNTY ItiYE {75) CTNS 0F ii{ILK TEA "m" 45OPCS I20040008
BUff\fiT 8l- M-02(i Al'R. 25,2020
!L li C0ltFi: 841$. Bl
,2
FIFTY (50) (j'INll Oii \tAi1'ri SP00N 'lL" 0000PCl;
16(H/18fi,i M*203
I{ S. C0l0: 71323. gl
3 FIFTY (50) (:lNIi OF'YA]Eft SPOON FE (i00oPCti
18$,flBffi{ M*204
l{ ti. (0l"rE: 'i 323. i)1
4 NINETY SIX (0(j) CTNS 0F r\g[1",8 {t, "F,Ii" 34 56PCS
M-137
H "$. Cfl]li: 732:i. t)l
5 0Nti l"ruNllHEir (100) CTNS 0F'r&jTTr.,t-j 3r" "ru" .i0Ur.]}'t.)r
M-009
H. S. Collrr: ?323. g)1
6 TWTiNIY EiGT{T (28) CTNS OF ffiT POT 11Zf.il{'ll;
11. Declaration by the exporter '12. Certification
The undersigned hereby declares that the above details and It is hereby certified, on the basis qf control carried out, that the
statement are correct; that all the products were produced in declaration by the exporter is correct.
*,9trffi&Hpr.!*ni- -
a nd that *& l.wll p,0CI,HQ,$u n tr fut il, . [,tft
" LL?i"o,o|.
these products in the Rules of Origin for the ACFTA for the
products exported to
rw$mu'rA rilffiilililrilfiilIilrlllr
;PoAing-C;'nt t
- - - - 1r r'.,r' o-t
Ilnngzlrnrr. China,AI,R. 21t,2.0't0
ffi#
Place and date, signature of authorised signatory
13.
fl lssued Retroactively [] Exhibition
Certificate E plac6na signKre ,r,nJilir,
I Movement tnird Party lnvoicing date, and stamp of certifying
1 958826
4
61
Original
1. Products consigned from (Exporter's business name, address, Reference No. gZOgOZSl23?6084i (PAGE 2 0F Z)
country)
* * * )t :t * * ** * * *.* **.* +* ** ASEAN.CHINA FREE TRADE AREA
PREFERENTIAL TARIFF
CERTIFICATE OF ORIGIN
(Combined Declaration and Certificate)
2. Products consigned to (Consignee's name, address, country)
FORM E
* ;t :f ,* ** * *** *,t ** *,k'k * * *
lssued in THE PEOPLE'S REPUBLIC OF CHINA
(Country)
See Overleaf Notes
3, Means of transport and route (as far as known)
4. For Official Use
Verif i.cat i.on : ori. gi tr. ctlt!: tomri. $ov. crt
Departure date [] Preferential Treatment Given
*****'t****
vessel's name / Aircraft etc.
fl Preferential Treatment Not Given (Please state reason/s)
Port of Discharge
Signature of Authorised Signatory of the lmporting Party
5. ltem 6. Marks and 7. Number and type of packages, description 8. Origin criteria 9. Gross weight or net 10. Number,
Number numbers on of products (including quantity where (see Overleaf weight or other quantity date of
packages appropriate and HS number in six digit code) Notes) and value (FOB) only lnvoices
when RVC criterion is
applied
?{*tiO$i M-011}
H $. C0lIi): 732iJ. ()1
,PE,
( Tf;MNTY EIG]T (2S) {:TN:I O! FRYPAN 18ffiI 67zPCl;
M*154
ll S. C0tlFl: 73?.3.92
)t,t* *** *** *** )t**
1'01lil,:F0l"JR l'ltJNDRFlll Al$ TWIiNTY ST.tlN
(42?) CTNii 0lLY.
11. Declaration by the exporter 12. Certification
The undersigned herebf declares that the above details and It is hereby certified; on the basis of qontrol carried out, that the
statement are correct; that all the products were produced in declaration by the exporter is correct.
- -----Esrr1i.affim # ir, "7 -*+:;-
and that th"y [Jil$& S,00.EBFJdi"
'[t]n0fi",,t$'o"IiLt..
these products in the Rules of Origin for the ACFTA for the
products exported to
sba
:r'n)n*rriiA lrfilffilllillllllllllltil illllilil |tt
I
<
>7
160
(lmporting Country)
qr+
llangz.trnu, China,APR. 2g,,?02A
NfaS (s
Place and date, signature of authorised signatory
I1nnez]nau..frnna, APR
'13. E lssued Retroactively fl exhibition
Place and date, signature and stamp of certifying
fl Movement Certificate I tfrird Party lnvoicing
