102203823059

1. Goods consigned from ( Exporter's business name, address, country) Reference No. 0100189/SBY/2020
CV. MAROV INTERNATIONAL
JALAN TANJUNG WIRA V/25, RT.05, RW.12 ASEAN-INDIA FREE TRADE AREA
GKB, DS. YOSOWILANGUN, PREFERENTIAL TARIFF
KEC. MANYAR, KAB. GRESIK 61151,
JAWA TIMUR, INDONESIA
CERTIFICATE OF ORIGIN
TEL : +62-81230920864 (Combined Declaration and Certificate)

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

FORM AI
BHATTACHARYA TIMBER Issued in INDONESIA
52, BHUPEN BOSE AVENUE (Country)
SHYAMBAZAR, KOLKATA - 700004
See Notes Overleaf

3. Means of transport and route (as far as known) 4. For Official Use
Preferential Tariff Treatment Given Under
ASEAN-India Free Trade Area Preferential Tariff
Departure Date SEPTEMBER 29, 2020

Vessel's name/Aircraft etc. ROTTERDAM BRIDGE V. 052N

Preferential Tariff Treatment Not Given (Please
state reason/s)
Port of Discharge KOLKATA, INDIA

.........................................................................................
Signature of Authorised Signatory of the Importing
Country

5. Item 6. Marks and 7. Number and type of packages, description of 8. Origin criterion 9. Gross weight or other 10. Number and
number numbers on goods (include quantity where appropriate and (see Notes overleaf) quantity and value (FOB) date of
Packages HS number of the importing country) Invoices

1 3 X 20' CONTAINERS STC : WO 64,428.80 KGM 19/MRV-05/INV/I

44 BUNDLES = 5,295 PCS = 64.4288 CBM USD 28,992.96 X/2020
OF BANGKIRAI SAWN SIZES SEPTEMBER
HS CODE : 4409.29.00 22, 2020

11. Declaration by the exporter 12. Certification

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

ISSUING OFFICE IN PROVINSI JAWA TIMUR

INDONESIA
........................................................................................................
(Country)

and that they comply with the origin requirements specified for
these goods in the ASEAN-India Free Trade Area Preferential
Tariff for the goods exported to

INDIA
..........................................................................................................
(Importing Country)

ABDIEL POPANG KABANGA

GRESIK, OCTOBER 1, 2020
.......................................................................................................... SURABAYA, OCTOBER 1, 2020
.......................................................................................................................
Place and date, signature of authorised signatory Place and date, signature and stamp of certifying authority

13. Where appropriate please tick:

Third Country Invoicing Exhibition Back-to-Back CO Cumulation

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