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

country)
ASEAN TRADE IN GOODS AGREEMENT
ASEAN INDUSTRIAL COOPERATION SCHEME
CERTIFICATE OF ORIGIN
(Combined Declaration and Certificate)
FORM D
2. Goods consigned to (Consignee's name, address,
Issued in INDONESIA
country)
(Country)
See Overleaf Notes

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

Preferential Treatment Given Under ASEAN

Departure Date Trade in Goods Agreement

Preferential Treatment Given Under ASEAN

Vessel's name/Aircraft etc. Industrial Cooperation Scheme

Preferential Treatment Not Given (Please

State reason's)
Port of Discharge
.................................................................................................................
Signature of Authorised Signatory of the Importing Country

5. Item 6. Marks and numbers 7. Number and type of packages, description 8. Origin criterion 9. Gross weight or other 10. Number and
number on packages of goods (including quantity where (see Overleaf Notes) Quantity and Value date of
appropriate and HS number of the (FOB) where RVC is Invoices
applied
importing country)

1 GW :
NW :

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 by
statement are correct; that all the goods were produced in the exporter is correct.

PROVINCIAL OFFICE IN MEDAN

..................................................I.N..D...O...N...E..S...I.A..............................
.................... (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

..................................................M....A..L..A...Y..S...I.A.................................
.................. (Importing Country)

....................................................M...E...D..A...N...,......................................
..............
Place and date, signature of authorised signatory

13.
Third Country Invoicing Exhibition

Accumulation De Minimis

Back-to-Back CO Issued Retroactively MEDAN,

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

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