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Mau D Co

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1. Goods consigned from (Exporter’s business name, Reference No.

VN-ID 17/02/
address, country)
ASEAN TRADE IN GOODS AGREEMENT/
TRUONG PHU VINH ONE MEMBER CO.,LTD ASEAN INDUSTRIAL COPPERATION SCHEME
348 D NGUYEN DINH CHIEU ST,PHU HUNG CERTIFICATE OF ORIGIN
VILLAGE,BEN TRE,VIET NAM (Combined Declaration and Certificate)
2. Goods consigned to (Consignee’s name, address, FORM D
country)
Issued in VIET NAM ..
PT DENIKIN INDUSTRI NUSANTARA (Country)
JL,WONOSOBO KERTEK KM 6,WONOSOBO-JAVA See Overleaf Notes
TENGAH ,INDONESIA
3. Means of transport and route (as far as known) 4. For Official Use

FROM CAT LAI PORT HO CHI MINH CITY Preferential Treatment Given Under
Departure date JAN 13 ,2017 ASEAN
Trade in Goods Agreement

Preferential Treatment Given Under


Vessel name/Aircraft ect ST EVER 005B ASEAN

Industrial Cooperation Scheme

Port of Discharge SEMARANG,INDONESIA Preferential Treatment Given (Please

state reason/s)
.............................................................................................
Signature of Authorised Signatory of the Importing Country
7. Number and type of packages,
6. Marks and 8. Origin 9. Gross wieght 10. Number
5. Item description of goods (including
numbers on criterion (see or other quantity and date of
number quantity where appropriate and HS
packages Overleaf Notes) and value (FOB) invoices
number of the importing country)

COCO CUTTING MACHINE


1 1-3 GW:900 KGS
84388090
FOB/USD 2,510 TPV-INDO/01
SKIVE CUTTING MACHINE
2 4-5 GW:400 KGS JAN 13,2017
84388090 RVC=45.89%
FOB/USD 2,273
GRACILARIA CUTTING MACHINE
3 6 GW:300 KGS
84388090
FOB/USD 1,737
MADE IN VIET NAM

11. Declaration by the exporter 12. Certification

The undersigned hereby declares that the above It is hereby certified, on the basis of control carrief out,
details and statemnet are correct; that all the goods that the declaration by the exporter is correct.
were produced in
VIET NAM
(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
INDONESIA
(Importing country)
JAN 18 , 2017 BEN TRE PROVINCE
Place and date, signature of
authorised signatory HO CHI MINH CITY,VIET NAM JAN 18,2017
Place and date, signature and stamp of
13. Third Country Invoicing certifying authority
Exhibition

Accumulation
De Minimis
Back-to-Back CO
Issued Retroactively
Partial Cumulation

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