PT POS INDONESIA (Persero) CUSTOMS DECLARATION CN 23

From Sender customs No. of item (barcode, if

Name : CANDRA reference (if any) | Maybe opened officially
De any)
Address : JALAN PURNAMA 2 DECLARATION EN DOUANE
No. of item (barcode, if | Maybe opened officially
Address (count)
any)
Postcode : 78121 City : KOTA PONTIANAK
State KALIMANTAN BARAT Country : ID-INDONESIA Declaration ID
To Name : CHAD ANTHONY C D S 0 1 2 1 9 2 3 9 0 2
A
Address : 2433 SANDRA DR Importer's references (if any) {tax code/VAT No./importer code) (optional)
Address (count)
Postcode 73110 City OKLAHOMA Importer's telephone/fax/email (if known)
Country US-UNITED STATES OF
State OKLAHOMA
AMERICA 4056184351 nursaidarifinal25@gmail.com

Net weight (3) For commersial item only

Detailed description of contents (1) Quantity (2) Total weight (4) Value (5) Total Value (6)
(in kg) HS tarif number (7) Country of origin of goods (8)
MITRAGYNA POWDER 1 5,0 5,0 10.00 USD 10 USD 121190
Category of item (10) Sales of goods Commercial sample Office origin/Date of posting
X Gift Returned Goods Other
29/01/2021 15:01
Documents Mixed content
Comments (11) : (e.g goods subject to quarantine, sanitary/phytosanitary inspection or other restriction) I certify that the particulars given in this custom
declaration are correct and that this item does not
contain any dangerous article or articles prohibited by
legisation or by postal or customs regulations
Licence (12) Certificate (13) Invoice (14) Date and sender's signature (15)
No(s). of licence(s) No(s). of certificate(s) No(s). of invoice 29/01/2021 15:01