ffi

1. Products consigned from (Exporter's business name, address, Reference No. E?01[A58C.{_m7 L 0n i
country)
.II,IAI'IGZHOIJ HI,IASHEI{C,I- IN i I'{TEF',NAT I ONAL
ASEAN.CHINA FREE TRADE AREA
TE.ANE CO. . L,TD.
iii,'OM ILOS },10. 1 !|EST ROAD.TIANFIE DISTF'ICT
PREFERENTIAL TARIFF
i I-|ANGZHOIJ, CIi]}iA CERTIFIGATE OF ORIGIN
(Combined Declaration and Gertificate)
2. Products consigned to (Consignee's name, address, country)
FORM E
PT. DAN&OOD I'{LISA}]TARA
.Ii,. PA}I RAYA LA_3A, GEBANGSAF',1, CEMJI( IND}H,
rEM-K, SEMAF}NG 501 14 II'{DOI{ESIA lssued in THE PEOPLE'S REPUBLIC OF CHINA
IELF. /FAX. (+61)2a (':595r9t (+n:):a 65!1519{/ (Country)
TAX ]D:01. 9ts2. 60!i. 4-51S. 000
See Overleaf Notes
3. Means of iransport and route (as far as known) 4. For Official Use
\ie :: i. f i c at i nn : r-u: i g i n. ar r,l st-,:rms. garv. c n

Departure date -I1-1I'1. 12, 202{,1

E Preferential Treatment Given

Vesset's name / Aircraft etc. 5pip116 pING 888I:006 il

E Preferential Treatment Not Given (Please state reason/s)
Port of Discharge SEi,tAR.AI,ri, Itt1p6ijEjIA

Signature of Authorised Signatory of the lmporting Party

6. Marks and 7. Number and type of package's, description 8. Origin criteria 9. Gross weight or net 10. Number,
numbers on of products (including quantity where (see Overleaf weight or other quantity, date of
packages appropriate and HS number in six digit code) Notes) and value (FOB) only lnvoices
when RVC criterion is
applied
VARNISi]ED B1.R.iH SLAT FOT{ BED 2500. 00!(CS r. S. DJ*DSI.]-
liS CODE: 940,3!-ril 2020060s
T,1Tr I . ('TV Ie \ Dl: 1 iTa irlli V JLIN. 0-q. ?01
i., l5L.D!A \U/ ! iLLCt,)
*** *** *** *** 'JtiLr
***
PT. DANiliT(JI] ANTAR.A

11. Declaration by the exporter 12. Certificaiion

The undersigned It is hereby certified, on the basis of control carried out, that the
statertrent are produced in declaration by the exporter is correct.

products exported to
ongrn

(lmporting Country)
specified for
tfie ACFTA for the

qp
Guangz-hou. China. JLIN. 17,20?0
Q
Place and date, signature of authorised signatory
4355339
l--luargzhou. Chin;r, Jllll. ld, 2020
E lssued Retroactively E Exhibition
E Movement Certificate E tfrirA Party lnvoicing Place and date, signature and stamp of certifying authority

19 48 024t0