1.

Goods consigned from (Exporter's business name, address, country)

Reference No. 012/KRW/2018
PT. KIMMY SHOES INDONESIA
JL. PERMATA RAYA
KAWASAN INDUSTRI KIIC KARAWANG,JAWA BARAT ASEAN TRADE IN GOODS AGREEMENT
ASEAN INDUSTRIAL COOPERATION SCHEME
41361, INDONESIA
CERTIFICATE OF ORIGIN
2. Goods consigned to (Consignee's name, address, country) (Combined Declaration and Certificate)
CHARLEON POKPHAND THAILAND FORM D
Issued in INDONESIA
KRUNG THEP MAHA NAKHON, BANGKOK 10110, (Country)
THAILAND See Overleaf Notes

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

Preferential Treatment Given Under ASEAN

Departure Date : 19 DECEMBER 2018 N/A Trade in Goods Agreement

Vessel's name/Aircraft etc. : CMA-CGM OTELLO Preferential Treatment Given Under ASEAN
Port of Discharge: LAEM CHABANG PORT Industrial Cooperation Scheme

Preferential Treatment Not Given (Please

State reason's)

.................................................................................................................
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 of goods (including quantity where (see Overleaf Quantity and Value date of
on appropriate and HS number of the Notes) (FOB) where RVC is Invoices
packages importing country) applied

1 Cont. HS 6405, KIMMY SHOES “WO”, 40%, 170.000 KGS, 19

20’X9’7” ALL TYPE AND MODELS “SP”, CTSH+ 160,000 THB DESEMBER
General MADE IN INDONESIA 35%, PC 25% 2018
Purpose
CONT.SLAC*
125 carton

11. Declaration by the exporter 12. Certification

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

DITFAS
PT. KIMMY SHOES INDONESIA
INDONESIA
and that they comply with the origin requirements specified for
these goods in the ASEAN Trade in Goods Agreement for the goods
exported to

CHARLEON POKPHAND THAILAND

THAILAND

JAKARTA, 19/12/2018
Place and date, signature of authorised signatory
13. PT. KIMMY SHOES INDONESIA,
Third Country InvoicingExhibition Karawang, 19 December 2018
AccumulationDe Minimis

Back-to-Back COIssued Retroactively

Partial Cumulation

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