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390718521 3

Goods Donsigned from {Exporter's businBss name, address. country) Reference n". 10247 21/SMRI2023
PT HOLI KARYA SAKTI
JL RAYA SEI\NARANG PURWODADI KM 28, MANGUNSARI, TEGOWANU, ASEAN-INDIA FREE TRADE AREA
GROBOGAN, JAWA TENGAH
INDONE$IA PREFERENTIAL TARIFF
CERTIFICATE OF ORIGIN
2 Goods consigned to (Consignee's name, address, country) {Combined Declaration and Certificate)
BHASEEN SPORTS PVT,LTD FORM AI
34 BASTI NAU JALANDHAR
PUNJAB 144002 lssued in INDqNE$IA.
INDIA (country)
MR,ZUBIN BHASEEN
91 -1 81 -501 0243 See Note* Overleaf

3. Means of transport and rouie (as far as known) A. -FAiffiAalnse

Shrpnrent Date APRIL 05, 2023
t:] Preferential Tanff Treatment Given Under
ASEAN-lndia Freo Trade Area Preferential Tarifi

Vessel's name/Aircraft etc UPS

Preferential Tariff Treatment Not Given (Please
state reason/s)

Fan of Discharge DELHI. }NDIA

Signature of Authorised Signatory of the lmpodng Country

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

1 BHASEEN GOLF .JLI RVC 80.50%+CTH 700.0000 PCE 1 1 31 -065lHKS-NGllv/z3/P

(rN DrA) OF GOLF GLOVES STYLE #5h/JML3C2 usD 4.270.0000 APRIL 03, 2023
ciNo, 1 - s HS: 61 16.10
I\'ADE IN sN2022008-0964
INDONESIA THIRD COUNTRY INVOICING BY APRIL 03,2023
IIIIZUNO SINGAPORE PTE LTD
51 Changi Business Park Central 2
#06-01 The Signature 486066
SINGAPORE

'1
. Declaration by the exporter 2. Ceniflcalion
The undersigned hereby declares that the above details and statements It is hereby c€rtified, on the bssis of control canied out, that the declaration
are coffect; that all the goods were produced in by the exporter is correci-

INDONESIA ISSUEo RETROACTTVELY. DATE OF $HlPl\iENT: ApRIL 05, 20?3

(Country)
ISSUING OFFICE IN PROVINSI JAWA TENGAH
and lhal they corhply lvith the origin requirements specified for these goods
in the ASEAN-lndia Free Trade Area Preferential Tariff for the goods
exported to

e,,d
**-"T*
F
TE NU. GROB
13,2423
H II,IAWAI'I PU JI NUGROHO
Place and date. of autharised signatory
$EMARANG, APRIL 13. 2023
Place and dute, signalurc *nd siamp cf cettifying auth'lnly

Where appropriate please trck:

Third Coun!ry lnvr:ieing f] r*r,iurri* 1*l Baek"tq-baek eO Curnulation

Form AI Serial AI -JA$ - S?6fr

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