Goods consingned from (exporter’s business name, address, country) Reference No. 1. Goods consigned to (consignee’s name, address, country) ASEAN-CHINA FREE TRADE AREA PREFERENTIAL TARIFF CERTIFICATE OF ORIGIN (Combined Declaration and Certificate) FORM E Issused in THE PEOPLE’S REPUBLIC OF CHINA Coumtry) See Notes overleaf 3.Means of transpor and route (as for as known) 4.For official use Preferential Treatment Given Depature date: Vessel's name/Aircraft etc: Preferential Treatment Not Given (pleae state reason/s) Port of discharge: Signature of Authorised Signatory of the Imprting Country 5.Item 6.Marks and 7.Number and type of packages, 8.Origin criterion (see 9.Gross weight or other 10.Number and date number numbers on description of goods (including Notes overleaf) quantity and value (FOB) of invoices packages quantity where appropriate and HS number of the importing Country) 1 11.Declaration by the exporter The undersigned hereby declares that the above details and 12.Certification Statement are correct, that all the goods were produced It is hereby certified, on the basis of control carried out , that the CHINA Declaration by the exporter is correct. (Country) and that they comply with the origin requirements specified for these goods in the ASEAN-CHINA Free trade Area referential Tariff for the goods exported to (Importing Country) Place and date.Signature of authorized signatory Place and date, Signautre and stamp of certifying authoriy
