5257384001

1 Goods consigned from (Exporter's business name, address, country) Reference No. 1001873/PDG/2023
PT RAJDULAR BROTHERS
JALAN GARUDA MUARO KASANG DALAM, KORONG SUNGAI PINANG, ASEAN-INDIA FREE TRADE AREA
KASANG BATANG ANAI, KASANG, BATANG ANAI, PADANG PARIAMAN,
SUMATERA BARAT PREFERENTIAL TARIFF
CERTIFICATE OF ORIGIN
2 Goods consigned to (Consignee's name, address, country) (Combined Declaration and Certificate)
TRIVENI IMPEX PVT . LTD
581/ 5 KATRA ISHWAR BHAWAN,
FORM AI
KHARI BAOLI, DELHI - 110006, INDIA Issued in INDONESIA
EMAIL : INFO@TRIVENIGROUP.IN *
(country)
See Notes Overleaf

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

Shipment Date MAY 25, 2023 Preferential Tariff Treatment Given Under
ASEAN-India Free Trade Area Preferential Tariff

Vessel's name/Aircraft etc DAYA MAJU V.DM1131S

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

Port of Discharge MUNDRA, INDIA ICD ACTL FARIDABAD,

INDIA

Signature of Authorised Signatory of the Importing Country

5. Item 6. Marks and 7. Number and type of packages, 8. Origin criterion 9. Gross weight or other 10. Number and date of
number numbers on description of goods (include quantity (see Notes quantity and value Invoices
Packages where appropriate and HS number of the overleaf) (FOB)
importing country)
1 CONTAINER/SEAL: 2X40' S.T.C : "WO" GW: RDB23S081
MRKU3468200/E00 1000 BAGS OF GAMBIER EXTRACT 51,400.0000 KGS MAY 22, 2023
9595 INVOICE NUMBER : RDB23S081 NW:
TGHU9226629/E00 INVOICE DATE : 22-05-2023 50,000.0000 KGS
9596 HS CODE : 3201.90.10 USD 139,983.2500
GROSS WEIGHT : 51,400.00 KGS
NETT WEIGHT :50,000.00 KGS

*GSTIN : 07AABCT2170N1Z6
PAN : AABCT2170N
IEC : 0599001160
CONTACT NUMBER : 011-47565004/5

NOTIFY PARTY:
TRIVENI IMPEX PVT. LTD
581/ 5 KATRA ISHWAR BHAWAN,
KHARI BAOLI, DELHI - 110006, INDIA
EMAIL : INFO@TRIVENIGROUP.IN
GSTIN : 07AABCT2170N1Z6
PAN : AABCT2170N
IEC : 0599001160
CONTACT NUMBER : 011-47565004/5
HS: 32019010

11. Declaration by the exporter 12. Certification

The undersigned hereby declares that the above details and statements 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

(Country)
ISSUING OFFICE IN PROVINSI SUMATERA BARAT
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)

PADANG PARIAMAN, MAY 29, 2023

RIDONALD
Place and date, signature of authorised signatory
PADANG, MAY 29, 2023
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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