1. Goods consigned from (Export's business name, address, country).

PT KARYAINDAH ALAM SEJAHTERA

JL. KALISOSOK KIDUL NO. 2, RT.004, RW,015
KREMBANGAN SELATAN - KREMBANGAN
SURABAYA - 60175, INDONESIA

2. Goods consigned to (Consignee's name, address, country). MINISTRY OF TRADE

OF THE REPUBLIC OF INDONESIA
KABORE KARIM CERTIFICATE OF ORIGIN
OUAGADOUGOU, SECTEUR 24 BURKINA FASO
TELEPHONE NO. +22678033444
FORM B
Reference No.

3. Means of transport and route (as far as known). 4. For official use.

Shipped by : MSC GIANNA V. HC851R

From : SURABAYA, INDONESIA

To : LOME, TOGO

Date of shipment : DECEMBER 29, 2018

5. Item 6. Marks and 7. Number and kind of packages; description of 8. Gross weight or 9. Number and
num- numbers of goods. other quantity date of invoices
ber. packages

1 167.58 MTS OF RBD PALM OLEIN IV57 JADU BRAND 20 LTR 176,890.00 KGM IJL-1812-000218
DECEMBER 21, 2018

10.Certification.

It is hereby certified, on the basis of control carried out, that the goods stated above were produced in Indonesia.

11.Competent authority (name, full address).

SURABAYA,
...............................................................................................

ISSUING OFFICE IN PROVINSI JAWA TIMUR

JL. SIWALAN KERTO UTARA II/NO. 42 SURABAYA
60236, JAWA TIMUR
(Signature) (Stamp)
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