DEPARTMENT OF THE TREASURY Aerodagh 22186 UNITED STATES CUSTOMS SERVICE ove Ne 115.0208 ‘NORTH AMERICAN FREE TRADE AGREEMENT CERTIFICATE OF ORIGIN Please prior type 1OCFR 181.11, 181.22 1. EXPORTER NAME AND ADDRESS ] 2. BLANKET PERIOD (DDIMM/YY) Samteec, Inc. FROM Scere coe a 520 Park East Blvd. oon New Albany, IN 47151 USA eee z - sae TAXIDENTIFCATION NUMMER: 351399589 14/01/13 3. PRODUCER NAME AND ADDRESS | IMPORTER NAME AND ADDRESS i ENSAMBLES ELECTRONICS INTEGRA Available to Customs Upon Request | 55’ "ARQUE INDUSTRIAL RIO REFORMA EL ALAMO, MEXICO 44490 “TAX IDENTIFICATION NUMBER: ‘TAX IDENTIFICATION NUMBER: EEI061025K64 A é DESCRIPTION OF GOOD(S) HS TARE cusssinication | peertiece NUMBER Printed Circuit Connectors 3536.69 TIM05-GF-S-RA-TR* *To Be Used Only With Shipment / Invoice # 3709409 TCERTIEY THAT: ‘+ THE INFORMATION ON THIS DOCUMENT IS TRUE AND ACCURATE AND I ASSUME THE RESPONSIBILITY FOR PROVING SUCH REPRESENTATIONS, | UNDERSTAND THAT I AM LIABLE FOR ANY FALSE STATEMENTS OR MATERIAL OMMISIONS MADE ON OR IN CONNECTION WITH THIS DOCUMENT; ‘+ LAGREE TO MAINTAIN, AND PRESENT UPON REQUEST, DOCUMENTATION NECESSARY TO SUPPORT THIS CERTIFICATE. AND‘TO INFORM, IN \WRITING, ALL PERSONS TO WHOM THE CERTIFICATE WAS GIVEN OF ANY CHANGES THAT COULD AFFECT THE ACCURACY OR VALIDITY OF ‘THIS CERTIFICATE; ‘+ THEGOODS ORIGINATED IN THE TERRITORY OF ONE OR MORE OP THE PARTIES, AND COMPLY WITH THE ORIGIN REQUIREMENTS SPECIFIED FOR THOSE GOODS IN THE NORTH AMERICAN FREE TRADE AGREEMENT, AND UNLESS SPECIFICALLY EXEMPTED IN ARTICLE 411 OR ANNEX 401, THERE HAS BEEN NO FURTHER PRODUCTION OR ANY OTHER OPERATION OUTSIDE THE TERRITORIES OF THE PARTIES; AND PAGES, INCLUDING ALL ATTACHMENTS, Tis COMPANY 1 Samtec, Inc. | i ie RATE (Frint of Type) Dane Chuck Hammond NAFTA Coordinator Te DRE DUNT eva ey pea THEMONE | ($12) 944-6733 G12) 948-5047 | Cita Fam STATS)