coo pak irwan

36938563852 Reference No. ASEAN TRADE IN GOODS AGREEMENT ASEAN INDUSTRIAL COOPERATION SCHEME CERTIFICATE OF ORIGIN (Combined Declaration and Certificate) FORM D Issued in INDONESIA (Country) See Overleaf Notes 1. Goods consigned from (Exporter's business name, address, country) 2. Goods consigned to (Consignee's name, address, country) 3. Means of transport and route (as far as known) Departure Date Vessel's name/Aircraft etc. Port of Discharge 4. For Official Use Preferential Treatment Given Under ASEAN Trade in Goods Agreement Preferential Treatment Given Under ASEAN Industrial Cooperation Scheme Preferential Treatment Not Given (Please State reason's) ................................................................................................................. Signature of Authorised Signatory of the Importing Country 5. Item number 6. Marks and numbers on packages 7. Number and type of packages, description of goods (including quantity where appropriate and HS number of the importing country) 8. Origin criterion (see Overleaf Notes) 9. Gross weight or other Quantity and Value (FOB) where RVC is applied 10. Number and date of Invoices 11. Declaration by the exporter The undersigned hereby declares that the above details and statement are correct; that all the goods were produced in ...................................................................................................................... (Country) and that they comply with the origin requirements specified for these goods in the ASEAN Trade in Goods Agreement for the goods exported to ...................................................................................................................... (Importing Country) ...................................................................................................................... Place and date, signature of authorised signatory 12. Certification It is hereby certified, on the basis of control carried out, that the declaration by the exporter is correct. ....................................................................................................................................... Place and date, signature and stamp of certifying authority 13. Third Country Invoicing Exhibition Accumulation De Minimis Back-to-Back CO Issued Retroactively Partial Cumulation 1 TGHU 3862623 / 0000189 1 X 20' CONTAINER STC: 1,515 CARTONS OF GENERAL CONSUMER GOODS 400 CTNS CANDY BAG (FRUIT&MINT;) 300 CTNS CANDY ROLL 200 CTNS HEMAVILTON DRINK 300 CTNS PALM FRUIT 200 CTNS POLO CANDY 15 CTNS AGAR-AGAR 100 CTNS EMPING HS.1704.90.99.00 HS.1704.90.99.00 HS.2008.91.00.00 HS.1704.90.99.00 HS.1302.31.00.00 HS.1904.20.90.00 =============================== HS: 2202.90.90.00 WO GW : 15,560.00 KGS (FIFTEEN THOUSAND FIVE HUNDRED AND SIXTY) NW : 13,810.00 KGS (THIRTEEN THOUSAND EIGHT HUNDRED AND TEN) 004/PLS-IF/III/2015 APRIL 30, 2015 0014478/JKB/2015 PT.PONY LAJU SEGARA GRAHA-AA-CIPTA PERKASA JL.RAYA DEWI SARTIKA NO.1 JAKARTA - INDONESIA HENG NAM IMP & EXP SDN BHD 2 JALAN 4 OFF JALAN CHAN SOW LIN G PO BOX NO 12487 50780 55200 KUALA LUMPUR - MALAYSIA MAY 8, 2015 COUGAR V.213 E PORT KELANG, MALAYSIA INDONESIA MALAYSIA INDONESIA, MAY 11, 2015 MUNICIPALITY OFFICE IN PURI KEMBANGAN TRININGSIH JAKARTA, MAY 11, 2015 v Page 1 / 1

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36938563852

Reference No.

ASEAN TRADE IN GOODS AGREEMENTASEAN INDUSTRIAL COOPERATION SCHEME

CERTIFICATE OF ORIGIN(Combined Declaration and Certificate)

FORM DIssued in INDONESIA

(Country)See Overleaf Notes

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

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

3. Means of transport and route (as far as known)

Departure Date

Vessel's name/Aircraft etc.

Port of Discharge

4. For Official Use

Preferential Treatment Given Under ASEANTrade in Goods Agreement

Preferential Treatment Given Under ASEANIndustrial Cooperation Scheme

Preferential Treatment Not Given (PleaseState reason's)

.................................................................................................................

Signature of Authorised Signatory of the Importing Country

5. Itemnumber

6. Marks andnumbers onpackages

7. Number and type of packages, description ofgoods (including quantity where appropriateand HS number of the importing country)

8. Origin criterion(see Overleaf Notes)

9. Gross weight or otherQuantity and Value(FOB) where RVC isapplied

10. Number anddate ofInvoices

11. Declaration by the exporterThe undersigned hereby declares that the above details and statementare correct; that all the goods were produced in

......................................................................................................................

(Country)and that they comply with the origin requirements specified forthese goods in the ASEAN Trade in Goods Agreement for the goodsexported to

......................................................................................................................

(Importing Country)

......................................................................................................................

Place and date, signature of authorised signatory

12. CertificationIt is hereby certified, on the basis of control carried out, that the declaration by the exporter is correct.

.......................................................................................................................................

Place and date, signature and stamp of certifying authority

13. Third Country Invoicing Exhibition

Accumulation De Minimis

Back-to-Back CO Issued Retroactively

Partial Cumulation

1 TGHU 3862623 /0000189

1 X 20' CONTAINER STC:1,515 CARTONS OF GENERAL CONSUMERGOODS400 CTNS CANDY BAG (FRUIT&MINT;)300 CTNS CANDY ROLL 200 CTNS HEMAVILTON DRINK300 CTNS PALM FRUIT200 CTNS POLO CANDY 15 CTNS AGAR-AGAR100 CTNS EMPINGHS.1704.90.99.00HS.1704.90.99.00HS.2008.91.00.00HS.1704.90.99.00HS.1302.31.00.00HS.1904.20.90.00

===============================

HS: 2202.90.90.00

WO GW : 15,560.00 KGS(FIFTEEN THOUSAND FIVEHUNDRED AND SIXTY)NW : 13,810.00 KGS(THIRTEEN THOUSANDEIGHT HUNDRED AND TEN)

004/PLS-IF/III/2015APRIL 30, 2015

0014478/JKB/2015PT.PONY LAJU SEGARAGRAHA-AA-CIPTA PERKASAJL.RAYA DEWI SARTIKA NO.1JAKARTA - INDONESIA

HENG NAM IMP & EXP SDN BHD2 JALAN 4 OFF JALAN CHAN SOW LIN G PO BOX NO 12487 50780 55200 KUALA LUMPUR - MALAYSIA

MAY 8, 2015

COUGAR V.213 E

PORT KELANG, MALAYSIA

INDONESIA

MALAYSIA

INDONESIA, MAY 11, 2015

MUNICIPALITY OFFICE IN PURI KEMBANGAN

TRININGSIH

JAKARTA, MAY 11, 2015v

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