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73706093500
1. Goods consigned from (Exporteds business name, address, country) ReferenceNo. 00O2622|KBS/2018
PT ADVIK INDONESIA
JL. SUNGKAI BLOK F.26 NO.19M ASEAN TRADE IN GOODS AGREEMENT
DELTA SILICON III LIPPO CIKARANG
BEKASI 17530 INDONESIA ASEAN INDUSTRIAL COOPERATION SCHEME
TLP : +62 21 29612158 CERTIFICATE OF ORIGIN
I AA IU . UUU' VUV (Combined Declaration and Certificate)
2. Goods consigned to (Consignee's name, address, country)
SDS INTERNATIONAL GROUP CO.,LTD.
FORM D
ROOM NO.8O1, PANAVONGS BUILDING lssued in INDONESIA
8TH FLOOR 104 SURAWONGS ROAD, (Country)
SIPRAYA, BANGRAK, BANGKOK-1O5OO, THAILAND See Overleaf Notes
TAX lD:0105524011579

3. Means of transport and route (as far as known) 4. For Official Use

t-------'l Preferential Treatment Given Under ASEAN

Departure Date JULY 2,2018 I I rrao" in coods Agreement
f------'l Preferential Treatment Given Under ASEAN
Vessel'sname/Aircraftetc. SQ0967 I I lnoustrlal Cooperation Scheme

f----l Preferential Trealment Not Given (Please

I I st t" reason's)
Port of Discharge BANGKOK, THAILAND

Signature of Authorised Signatory of the lmporting Country

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

539 KGS 1 806/t NV/o0062-E

1 SDS INTERNATIONAL 2 PALLETS OF
GROUP CO.,LTD LIFTER, ASSY TENSIONER (FIVE HUNDRED AND JUNE 28, 2018
YOUR PART NO. 1 4520-K46-N21 0-N/1 THIRTY-NINE)
14520-K46-N21 0-M1
DIMS: 144X104X63/1
144X104X10611

HS: 8714,'10.90

1 1. Declaration by the exporter 12. Certiflcation

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.

ISSUING OFFICE IN KOTA BEKASI

INDONESIA
(Country)

and that they comply with the origin requirements specified for
these goods in the ASF(qN Trade in Goods Agreement for the goods
exported to

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Place and date, sig

"' E tnvoicing
rhird country n Exhibition

tr Accumutation tr De Minimis

E Back{o-Backco
i ' tr lssuedRetroactively , JULY 3, 2018

Place and date, signature and stamp of certifying authority

tr Partial Cumulation