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The undersigned _________ (owner or agent),does hereby declare for the above named shipper, the goods as described above were shipped
on the above date and consigned as indicated and are products of the Guangzhou China
Dated at __________ on ________
Sworn to before me on _____________
The _______________________________________, a recognized Chamber of commerce under the laws of the Sate of _______
, certifies, in reliance on the exporters representation and not on the basis of independent verification, that to the best of its knowledge and
belief, the products named in this documentoriginated in the Guangzhou China.
Secretary ___________________________