CERTIFICATE OF ORIGIN

1.Goods consigned from (exporter business Reference No : 0001/JKT/2015

name, address, country)
PT. YUSMAN GALIH PRAYOGA A
JALAN RAYA DEMAK KM. 9 SAYUNG, DEMAK
GENERALIZED SYSTEM OF REFERENCES
CERTIFICATE OF ORIGIN
(Combined declaration and certificate)
2. Goods consigned to (consigned’s name,
address, country)
FORM A
LOUIS FASHION INC.,
BURSTAH 42, 20457 HAMBURG Issued in Indonesia.
(Country)
GERMANY
Sea notes overleaf
3. Shipped : by MAERSK REGALS V 001R 4. For Official use

Means of Transport and route (as far known) Isued restros pectrively
FROM : DEMAK, INDONESIA
TO : HAMBURG, GERMANY

BY : MAERSK REGALS V 001 R

Dated of shipped : 20 JUNI 2021

5. Item 6. Marks 7. Number and kind of 8. Origin 9. 10. Number and date of
number and packages, description of criterion Gross invoice
number of goods weight
package or other
quantity
MEN’S COAT
1 SEAL: AS PER SUPLIER PROFORMA DEMAK, 33,000 181904230/MC/VI/2021
40% COTTON 60% POLYESTER INDONESIA KGS
GR130997 15 JUNI 2021
H55-105CM SHIPPING MARKS
SEAL: LF STYLE 208-2021
GR131095
SEAL:
GR131094

11. Certification 12. Declaration by the exporter

It is hereby certified, on the basis of control The undersigned hereby declare that the above details
carried out, that the declaration by the exporter and statements are correct : that all the goods were
is correct

Produced in INDONESIA

And that they comply with the origin requirements

specified for those goods in the generalized system of
preferences for goods exported to UK

Jakarta,
Place and date, signature of authorized signatory
Jakarta, INDONESIA
…..……………………………………………………
Place and date, signature and stamp of certifing
authority