HrY 7.1.

39{*4
Original
'1. Products consigned from (Exporter's business name, address, Reference No.
country) 8174702C]08,i0210
::il+-Ml.]EN XImE$€Nfi TI{AD;.NG i;0. ,Lni ASEAN-CHINA FREE TRADE AREA
-n00u ?620, rriArln BU1l,DrN6" (fiA]qjf'ENG
oAt$sN PREFERENTIAL TARIFF
CH|.hFlr]Mi R0AD, U$-{J I)iS'tRlCT" :;IflM}iuN (itliM CERTIFICATE OF ORIGIN
(Combined Declaration and Certificate)
2. Products consigned to (Consignee's name, address, country)
FORM E
P'I 'iRnfJOIMN PRffA PB\Ki'IiA
.lL H YAM StniLK 4 FX .IAI(AR'jA 10i20 il\D0fujl1i
lssued in THE PEOPLE'S REPUBLIC OF CHINA
(Country)

See Overleaf Notes

3. Means of transpori and route (as far as known) 4- For official Use vsrri icatiol: w*r. r:liraorigll. gr;. i:r
Departure date Tl Preferential Treatmeni Given
Mrrr. 05" ?01?
vessel's narne / Aircraft etc c0s{:0 sANT0:r 0:[s I Preferential Treatrnent Not Given (Please state reason/s)
Port of Discharge
.TAKARTA, IrvxNEsIA

Signaiure ofAuthorised Signatory ofthe lmporting Party

5. ltem 6. [4arks and 7. Number and type of packages, description B. Origin criterla L Gross weight or '10. Number and
number numbers of of products (including quantity where (see Overleaf other quantity date of
packaqes appropriate and HS number of the Notes) and value (FOB) invoices
importing Party)

t- N/M RM:TiI\KJLI"AR T\LTn{IN] IJM flIRE s5% 5058.4!n\Cl

P 1 17&.){f)4 USI] .I34q6. 9? TPPAgl '1i (:
2.8*.12.8 r,[Ap t)ii , ?f ! 7
l[' ij0L[; 854419

:) N/M RE0TAMi_I-AR d-iI{IN1t-!r fli!€ 93h 2220.37K(iS

Pl l7006r'4 Ui.il) i5392. 2{
1. &;5. 5
HS (otE 854419

loTil: ltRE (3) PAIETS oNLY

*** *** *++ $:14
**,1 t*ji
FLYTNc ELitCTRI(j (H0N{ti0N6) C0., LlMITti)
TNi T A9 ,
EIF :JILVERC*P 1MI'RNAi.iOI'iAi .
romR ?0'l 7 li M |HAN kOAD, M0N(,KO,i
KCYLO(N HOIq*,OM

11 . Declaration by the exporter 12 Certification

The undersigned hereby declares that the above details and lt is hereby ceftified, on lhe basrs of controT carried out, that the
staternent are correct; that all the products were produced in
CHINA
(Country) Niililiill[fliil illt mtil5{
iluu[u5st ILI$!r .z"q}'r!_4"\
and that requirements specified for
,16:- ';9
these for the ACFTA for the t4; tttt
6Efiiril '-J

'}J{'ff[].uZ
:\:.-,;,r/
Sleuz!,en, itrii; h\WM
Place and date, signatu.e of authorised signatory
'1
3. ih*.uzlren" Chilq ldAR. Ai
"20i7
E lssued Retroact vely - Exhibilion
! lr4ovement Certificate n Third Party Invoicing PLace and date, signature and stamp of certifylnq author ty

AQSIQ 161ss3035