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1. Goods consigned from (Exporter's business name, address, country) Reference No.

PT ADYABOGA PRANATA INDUSTRIES


PUSAT NIAGA ROXY MAS BLOK C 5 NO.3
JL. KH. HASYIM ASHARI JAKARTA 10150
ASEAN TRADE IN GOODS AGREEMENT
INDONESIA ASEAN INDUSTRIAL COOPERATION SCHEME
CERTIFICATE OF ORIGIN
2. Goods consigned to (Consignee's name, address, country) (Combined Declaration and Certificate)
KHONG GUAN ENTERPRISE SDN . BHD FORM D
46 & 48, JALAN MIDAH SATU, TAMAN MIDAH, Issued in INDONESIA
JALAN CHERAS, 56000 CHERAS, (Country)
KUALA LUMPUR, MALAYSIA
TEL : +607 5992628 See Overleaf Notes
FAX : +607 5992991
3. Means of transport and route (as far as known) 4. For Official Use

Preferential Treatment Given Under ASEAN


Departure Date APRIL 23, 2018 Trade in Goods Agreement

Preferential Treatment Given Under ASEAN


Vessel's name/Aircraft etc. CSCL HOUSTON V.0060N Industrial Cooperation Scheme

Preferential Treatment Not Given (Please


State reason's)
Port of Discharge PASIR GUDANG, JOHOR,
.................................................................................................................
MALAYSIA
Signature of Authorised Signatory of the Importing Country

5. Item 6. Marks and 7. Number and type of packages, description 8. Origin criterion 9. Gross weight or other 10. Number and
number numbers on of goods (including quantity where (see Overleaf Notes) Quantity and Value date of
packages appropriate (FOB) where RVC is Invoices
and HS number of the importing country) applied

1 1X40' HC CONTAINER CONSIST OF RVC.100% 15,520 KGM 1904-12/INV/AP/JH


(FIFTEEN THOUSAND FIVE R/2018
4850 CARTONS OF ICED GEM BISCUITS HUNDRED AND TWENTY) APRIL 19, 2018
HS: 1905.31.10 USD 24,958
(TWENTY-FOUR
THOUSAND NINE
HUNDRED AND
FIFTY-EIGHT)

11. Declaration by the exporter 12. Certification


The undersigned hereby declares that the above details and statement It is hereby certified, on the basis of control carried out, that the declaration
are correct; that all the goods were produced in by the exporter is correct.

INDONESIA
ISSUING OFFICE IN KOTA ADMINISTRASI JAKARTA
......................................................................................................................
(Country)
PUSAT
and that they comply with the origin requirements specified for
these goods in the ASEAN Trade in Goods Agreement for the goods
exported to

MALAYSIA
......................................................................................................................
(Importing Country)

JAKARTA,
......................................................................................................................
Place and date, signature of authorised signatory

13.
Third Country Invoicing Exhibition

Accumulation De Minimis

Back-to-Back CO Issued Retroactively


,
.......................................................................................................................................
Partial Cumulation
Place and date, signature and stamp of certifying authority

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