1. Goods consigned from (Exporter's business name, address, country) Reference No.

PT. INDAH KARYA (PERSERO)

JL GOLF NO. 2A, ARCAMANIK, BANDUNG
INDONESIA
ASEAN TRADE IN GOODS AGREEMENT
TEL : (62-22) 7834092, 7834093, 7807971 ASEAN INDUSTRIAL COOPERATION SCHEME
FAX : (62-22) 7834093, 7807971 CERTIFICATE OF ORIGIN
2. Goods consigned to (Consignee's name, address, country) (Combined Declaration and Certificate)
VSIM ENTERPRISE SDN BHD FORM D
NO. 25-02 BLOK J Issued in INDONESIA
JALAN KOTA 1/2 ,TAMAN CAHAYA PUTERI (Country)
81750, MASAI, JOHOR BAHRU- MALAYSIA
See Overleaf Notes

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

Preferential Treatment Given Under ASEAN

Departure Date SEPTEMBER 29, 2020 Trade in Goods Agreement

Preferential Treatment Given Under ASEAN

Vessel's name/Aircraft etc. YM INTERACTION 206W Industrial Cooperation Scheme

Preferential Treatment Not Given (Please

State reason's)
Port of Discharge PORT KLANG, MALAYSIA
.................................................................................................................
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 on of goods (including quantity where (see Overleaf Notes) Quantity and Value date of
packages appropriate (FOB) where RVC is Invoices
and HS number of the importing country) applied

1 SEGU-4774982 / 1X40'HC STC: WO 23,998.000 KGM 038.0/02.01.INVPL

IDSUB-82000132 19 CRATES = 19,998.000 KGS = 57.7260 M3 Y/DIV.IND/IX/2020
OF INDONESIAN PLYWOOD. SEPTEMBER 22,
MR.SPECIES PARASERIANTHES 2020
FALCATARIA

HS: 4412.31.00

11. Declaration by the exporter 12. Certification

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

INDONESIA
ISSUING OFFICE IN PROVINSI JAWA TIMUR
......................................................................................................................
(Country)
and that they comply with the origin requirements specified for
these goods in the ASEAN Trade in Goods Agreement for the goods
exported to

MALAYSIA
......................................................................................................................
(Importing Country)

BANDUNG,
......................................................................................................................
Place and date, signature of authorised signatory

13.
Third Country Invoicing Exhibition

Accumulation De Minimis

Back-to-Back CO v Issued Retroactively

,
.......................................................................................................................................
Partial Cumulation
Place and date, signature and stamp of certifying authority

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