1. Products consigned from (Exporter's business name, address, country) Reference No.

PT. FAJAR BERSERI

JL. PLTU AIR ANYER DUSUN MUDEL MERAWANG BANGKA, ASEAN-CHINA FREE TRADE AREA
PROVINSI KEPULAUAN BANGKA BELITUNG, INDONESIA PREFERENTIAL TARIFF
CERTIFICATE OF ORIGIN
(Combined Declaration and Certificate)
2. Products consigned to (Consignee's name, address, country)
FORM E
TO ORDER, NOTIFY PARTY : ORIENT GROUP COMMODITIES IMPORT
AND EXPORT CO.,LTD
ADDRESS: 5A, DOUBLE DOVE GREAT TOWER, NO.438 PUDIAN Issued in INDONESIA
ROAD, PUDONG NEW
DISTRICT, SHANGHAI, CHINA 200122
TEL: +86 021-61766520 See Overleaf Notes
FAX: +86 021-61766525
3. Means of transport and route (as far as known) 4. For Official use

Departure Date APRIL 3, 2021 Preferential Treatment Given

Vessel's name/Aircraft etc. BG. SINDO GARUDA KENCANA V.165 JN / Preferential Treatment Not Given (Please state reason/s)
TB. SD DIAMOND

MV. AEGIALI V.2102E .................................................................................................................

Port of Discharge QINGDAO
Signature of Authorised Signatory of the Importing Party

5. Item 6. Marks and 7. Number and type of packages, 8. Origin criteria 9. Gross weight 10. Number,
number numbers of description of products (including (see Overleaf or net weight or date of invoices
packages quantity where appropriate and Notes) other quantity and
HS number in six digit code) value (FOB) only
when RVC
criterion is applied

1 MIXTURES OF 160 PALLETS 100% GW : 002-INV/FB-IV/21

SIR20 AND 205,120 KGM APRIL 1, 2021
SBR1502 COMMODITY: MIXTURES OF SIR20 AND NW :
PRODUCE OF SBR1502 201,600 KGM
INDONESIA ORIGIN : INDONESIA USD 302,565.30
QINGDAO, CHINA QUANTITY : 201.6MT
GROSS WEIGHT : PACKING : IN 1.26MT PER
205.120KGS NETT SHRINKWRAPPED UNIT
WEIGTH : 201.600
KGS
MANUFACTURING EXPORTING COUNTRY HS CODE :
DATE : MARCH 22 4002.80.90
- 31,2021 IMPORTING COUNTRY HS CODE :
4002.80.00

HS: 400280

11. Declaration by the exporter 12. Certification

The undersigned hereby declares that the above details and statement are It is hereby certified, on the basis of control carried out, that the declaration by
correct; that all the products were produced in the exporter is correct

INDONESIA ISSUING OFFICE IN PROVINSI KEPULAUAN

.....................................................................
(Country) BANGKA BELITUNG
and that they comply with the origin requirements specified for these
products in the Rules of Origin for the ACFTA for the products exported to

CHINA
.....................................................................
(Importing Country)

MERAWANG,
..........................................................................................................
Place and date, signature of authorised signatory

13.
v
Issued Retroactively Exhibition PANGKALPINANG,
.............................................................................................................
Movement Certificate Third Party Invoicing Place and date, signature and stamp of certifying authority

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