49651474031

1. Goods consigned from ( exporter's business name, address,

country)

Reference No.

PT APPAREL ONE INDONESIA

KAWASAN RUKTI MUKTI BAWANA B-05 JL. RAYA SEMARANG KENDAL
KM.12, RANDU GARUT, TUGU, SEMARANG
PHONE : +62 24 8664484/FAX : +62 24 8664483
INDONESIA

0047702/SMR/2016

GENERALIZED SYSTEM OF PREFERENCES

CERTIFICATE OF ORIGIN
(Combined declaration and certificate)

2. Goods consigned to (consignee's name, address, country)

FORM A

ADIDAS INTERNATIONAL TRADING BV

ATLAS ARENA, AFRIKA BUILDING, HOOGOORDDREEF 9A
1101 BA AMSTERDAM ZO
PHONE : 31205734540
THE NETHERLANDS

Issued in INDONESIA
(country)

See notes overleaf

3. Means of transport and route (as far as known)

4. For official use

ISSUED RETROSPECTIVELY

SHIPPED BY

BY AIR

FROM

SOEKARNO HATTA , JAKARTA

TO

AMSTERDAM , NETHERLANDS

DATE OF

JUNE 26, 2016

SHIPMENT

5. Item
number
1

6. Marks and
numbers of
packages

7. Number and kind of packages; description of goods

CUST. O/N.:
PO.NO.:
ART.NO.:
SIZE:
QTY:
MADE IN INDONESIA

1 CARTON = 2 PCE
UNISEX TRACK SUIT (JACKET + PANTS)
100% POLYESTER (KNITTED)
CUSTOMER NO.516222 STYLE NO.OIS16250804
PO.NO. 0115420791 ART. NO. S95994

8. Origin
criterion
(see notes
overleaf)
W
6112

9. Gross weight
or other
quantity
1.28 KGM

10. Number
and date of
invoices
AO21606/0517
JUNE 16, 2016

ZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZZ

11. Certification

12. Declaration by the exporter

It is hereby certified, on the basis of control carried out, that

the declaration by the exporter is correct.

PROVINCIAL OFFICE IN SEMARANG

The undersigned hereby declares that the above details and

statements are correct; that all the goods were
INDONESIA
produced in ..............................................................................
(country)

and that they comply with the origin requirements specified

for those goods in the generalized system of preferences for
goods exported to
NETHERLANDS
..................................................................................................
(importing country)
SEMARANG, JUNE 27, 2016

SEMARANG, JUNE 27, 2016

.....................................................................................................

..................................................................................................

Place and date, signature and stamp of certifying authority

Place and date, signature of authorized signatory

Page 1 / 1