1. Goods consigned from (Exporter's business name, address, country) Reference No.
CV SAWERIGADING JAYA RAYA
JL.JAWI-JAWI NO.58
SELATPANJANG-RIAU
ASEAN TRADE IN GOODS AGREEMENT
INDONESIA ASEAN INDUSTRIAL COOPERATION SCHEME
CERTIFICATE OF ORIGIN
2. Goods consigned to (Consignee's name, address, country) (Combined Declaration and Certificate)
FAMA CORPORATION SDN BHD FORM D
NO.5, JALAN 2/8, DATARAN TEMPLER BANDAR BARU SELAYANG 68100 BATU Issued in INDONESIA
CAVES SELANGOR (Country)
MALAYSIA
See Overleaf Notes
3. Means of transport and route (as far as known) 4. For Official Use
Preferential Treatment Given Under ASEAN
Departure Date JUNE 23, 2019 Trade in Goods Agreement
Preferential Treatment Given Under ASEAN
Vessel's name/Aircraft etc. DUA SAUDARA 3 Industrial Cooperation Scheme
Preferential Treatment Not Given (Please
State reason's)
Port of Discharge BATU PAHAT
.................................................................................................................
Signature of Authorised Signatory of the Importing Country
5. Item 6. Marks and 7. Number and type of packages, description 8. Origin criterion 9. Gross weight or other 10. Number and
number numbers on of goods (including quantity where (see Overleaf Notes) Quantity and Value date of
packages appropriate (FOB) where RVC is Invoices
and HS number of the importing country) applied
1 50,000 PIECES KELAPA BULAT "WO" NW : 07/SJR/INV/VI/SLP/
HS: 0801.19.90 50,000 KGM 2019
(FIFTY THOUSAND) JUNE 17, 2019
11. Declaration by the exporter 12. Certification
The undersigned hereby declares that the above details and statement It is hereby certified, on the basis of control carried out, that the declaration
are correct; that all the goods were produced in by the exporter is correct.
INDONESIA
ISSUING OFFICE IN KOTA DUMAI
......................................................................................................................
(Country)
and that they comply with the origin requirements specified for
these goods in the ASEAN Trade in Goods Agreement for the goods
exported to
MALAYSIA
......................................................................................................................
(Importing Country)
SELAT PANJANG,
......................................................................................................................
Place and date, signature of authorised signatory
13.
Third Country Invoicing Exhibition
Accumulation De Minimis
Back-to-Back CO Issued Retroactively
,
.......................................................................................................................................
Partial Cumulation
Place and date, signature and stamp of certifying authority
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