1.        Goods consigned from (Exporter’s business name..)
Address country:
PT.NUSA INDAH JAYA
JL. KEBON BAWANG VI NO.xx
KEBON BAWANG,TANJUGPRILK
JAKATRAUTARA 143xx INDONESIA 
 
Reference No.   00964/JKB/2010
ASEAN CHINA FREE TRADE AREA
PREFERENTIAL TARIFF
CERTIFICATE OF ORIGN
(combined declaration certificate)
FROM E
Issued in INDONESIA
(Contry)
(see notes overleaf)
2.        Goods consigned to Consignee’s name, address,country
JIANGMEN HONGXING ECONOMY TRADING LMP.& EXP,L/T/D
ROOM xxx,NO.xx KANGKOU 2 ROAD JIANGMEN GUANGDONG
TEL:010-82281XXX    FAX:020-82281XXX
3.        Means of transport and route (as far as known)
Deoature date
MAY 02,2010/11/16
Vessels name/ aircraft etc
NAJADE 1010
Port of discharge
HUANGPU OLD PORT,CHINA 4.        For OFFICIAL Use
Preferential treatment given ASEAN-CHINA
Free trade Area preferential taniff
_______________________
Preferential treatment not given (please state reasons)
_______________________
-----------------------------------
Signature of authorize signature of the country
5.ITEM number 6.marks and numbers on packages
CONT No.:
MWCU5336689
SEAL NO.:ML-ID0840482 7.Number and type of packages ;description of goods including quantity where appropriate and HS number of importing country
1×40’ RH S.T.C.
2,720 master cartons
-FROZEN RIBBON FISH HS.0303.79.1000 8.Origin criterion (see Notes overleaf)
“X” 9.Gross weight or other quantity and value(FOB)
 
 
27.200.00KGS
USD 17,080.00 10.Number and date of invoice
095/NIJ/iv/10
April 27,2010
 
11.Declaration by the exporter
The undersigned hereby declares that the above details and statement are correct ,that all the goods were produced in INDONESIA
And that they comply with the origin requirements specified for the goods in the ASEAN-CHINA free trade Area preferential tariff for the goods exported to CHINA(Importing country)
JAKARTA,MAY4,2010
Place and date,signature of authorized signatory
  12. Certification
It is hereby certified ,on the basis of control carried out, that the declaration of the exporter is correct.
 
JAKARTA,MAY4,2010
Place and date signature and stamp of certifying