1.

Goods consigned from (exporter's business name, address, country, Reference

including province or state) No

CERTIFICATE OF ORIGIN
Country Issued (Include Region, Province, or

2. Goods consigned to (consignee's name, address, country, including

province or state)
4. Means of Transport and Route (as far a

Producer Name / Manufacting Location (MUST provide producer's business 5. For official use
3. name, including specific manufacturing address, country, including province
or state)

Description of Goods &

6. Marks and Numbers 7. Part Number 8. 9.
Quantity

11. Certification 12. Declaration by the exporter:

The undersigned hereby declares that t
details and statements are correct; that
It is hereby certified, on the basis of control carried out, that the declaration
were produced in (name country) and th
by the exporter is correct.
comply with the origin requirements spe
goods exported to
Place and date, signature and stamp of certifying authority Place and date, signature of authorized signatory
RTIFICATE OF ORIGIN
ry Issued (Include Region, Province, or State)

Means of Transport and Route (as far as known)

For official use

Number and date

HTS 10.
of invoices

Declaration by the exporter:

The undersigned hereby declares that the above
details and statements are correct; that all the goods
were produced in (name country) and that they
comply with the origin requirements specified for
goods exported to

(importing country)
Place and date, signature of authorized signatory