Triplicate 1. Good, consigned from (Exporter’s business name, address, country) PT. CHEIL ABRASIVE INDONESIA JL. ITH BLOKC-8 NO. 124 KAWASAN INDUSTRI BILE LEMAH ABANG BEKAS! [i senceenlia ah 2. Good consigned to (Consignee's name, address, country) ABC CO., LTO NO.B0, 80 DE STREET, LONG BIEN DISTRICT, HANO!, VIETNAM TEL:84-4- References No. 3904/BKV06/2010 ASEAN COMMON EFFECTIVE PREFERENTIAL ‘TARIFF /ASEAN INDUSTRIAL COOPERATION SCHEME (CERTIFICATEOF ORIGIN (Combined Declaration and Certificate) FORMD Issuedin INDONESIA (Country) See Notes Overteat 3. Meains of transport-and route (as far'as Known) Departure date ‘AUGUST 12, 2010 \Vessel's namelAlircraft etc KOTA HARTA V.HTA 754 Port of Discharge: Saat 4. For Official Use Profefenal Treatment ven Under ASEAN Common Etfective Preferential Tanff Scheme referent Treatment Given Undor ASEAN Industrial Cooperation Scheme Preferential Treatment Nat Given (Please sale reasons) Signature of Authorised Signatory ofthe Importing Country 80 7,400.00 \ HS No, : 6804, 10.6000 4 S.item | 6. Marksand Number and type of packages, description of |_| 8. Originciterion} 9.,Gross weightor | 10. Number and date umber | fumberon ‘00d (including quantty where appropriate (see Notes ‘ther quanty of invoices packages ‘and HS numberof the Importing country) Overieat) ‘and value (FOB) 1 ‘ABC CO., LT0 [4 Px. AVC 81.82% ..9,40.00KGS | Ci-100800109-VT OINO:OB/APN-C | = 6,000 PCS OF KPRIXABRASIVEWHEELS | ~ (THREE HEIL THOUSAND ‘AUGUST 09, 2010 HAIPHONG ‘SELLER THREE PINO:1-4 HEIL GRINDING WHEEL IND. CO.,LTD. HUNDRED MADE IN 140-2 JANGHEUNG-DONG NAM-GU FORTY) INDONESIA, POHANG-Si \ GYEONGSANGBUK-DO, KOREA usp 6,746.00 ‘11. Declaration by the exporter ‘The undersigned hereby declares that the above details and statement are correct; that all the goods were produced in INDONESIA (County) aid that they comply with the origin requirements specified for these goods in the ASEAN Common Effective Preferential Tarif Seheme for the goods exported to au seenrandeltinn = ist 12. Certification ‘exporter is correct Place and dat, [0 Trie-County invoicing 1 Exhibition Di Accumulation Bde minimis . D1 BecktoBack co [i tsoued Retroactvely D1 Paral cumulation Sy BEKAS! , AUGUST 13, 2010 signature and stamp of certying authority x Its Hereby certited, bn the basis of contro! carried out, that the deciaration by the SERIAL D2-00 2544 toft