You are on page 1of 1

1. Goods consigned from ( exporter's business name, address, Reference No.

country)
PT LOGISTIK MANDIRI SAKTI
JL KISAMAUN GG. BALAI WARGA BABAKAN MASJID, NOMOR -, RT 003,
RW 007 GENERALIZED SYSTEM OF PREFERENCES
INDONESIA
CERTIFICATE OF ORIGIN
2. Goods consigned to (consignee's name, address, country) (Combined declaration and certificate)

URVINA, S.L FORM A


POL. IND, LAS VIAS VAVE 24
Issued in INDONESIA
CTRA. DE LOGRONO, KM 19
(country)
50298-PINSEQUE (ZARAGOZA),
SPAIN
See notes overleaf
3. Means of transport and route (as far as known) 4. For official use

SHIPPED BY : BY AIR

FROM : SOEKARNO HATTA

TO : BARCELONA

DATE OF : JANUARY 29, 2018


SHIPMENT

5. Item 6. Marks and 7. Number and kind of packages; description of goods 8. Origin 9. Gross weight 10. Number
num numbers of criterion or other and date of
-ber packages (see notes quantity invoices
overleaf)
1 156 CARTONS P GW : 001/FI-EXP/I/2018
SAID TO CONTAIN : 1,386.39 KGS JANUARY 23,
156 CARTONS OF NW : 2018
-VW PRODUCTION MEN JACKET (J022824) 1,261.59 KGS
-VW PRODUCTION MEN TROUSERS (J022825)
-VW PRODUCTION WOMEN TROUSERS (J022826)

HS CODE : 6203.32.10
6203.42.10
6204.62.00

11. Certification 12. Declaration by the exporter


It is hereby certified, on the basis of control carried out, that The undersigned hereby declares that the above details and
the declaration by the exporter is correct. statements are correct; that all the goods were
INDONESIA
produced in ..............................................................................
MUNICIPALITY OFFICE IN TANGERANG (country)
and that they comply with the origin requirements specified
for those goods in the generalized system of preferences for
goods exported to

SPAIN
..................................................................................................
(importing country)
, TANGERANG,
..................................................................................................... ..................................................................................................
Place and date, signature and stamp of certifying authority Place and date, signature of authorized signatory

Page 1 / 1

You might also like