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3. Means of transport and route (as far as known) 4. For Official Use
Departure Date: 29/11/2023 ☐ Preferential Treatment Given Under ASEAN Trade in Goods Agreement
Vessel's name/Aircraft etc.: BY TRUCK
☐ Preferential Treatment Not Given (Please state reason/s)
Port of Discharge: OTHER (VIETNAM)
..........................................................................................
Signature of Authorised Signatory of the Customs Authority of the Importing Country
5. Item number 6. Marks and numbers on 7. Number and type of packages, description of 8. Origin criterion 9. Gross weight or 10. Number and
packages goods (including quantity where appropriate and (see Overleaf other quantity and date of invoices
HS number of the importing country) Notes) FOB price where
RVC is applied
HS CODE: 76042910
The undersigned hereby declares that the above details and statements are It is hereby certified, on the basis of control carried out, that the
correct; that all the goods were produced in declaration by the exporter is correct.
VIET NAM
(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
VIETNAM
(Importing country)
Accumulation De Minimis
Partial Cumulation
Page 1 / 4
ORIGINAL
Reference No. VN-VN 23/77/003109
1. Goods Consigned from (Exporter's business name, address, country)
3. Means of transport and route (as far as known) 4. For Official Use
Departure Date: 29/11/2023 ☐ Preferential Treatment Given Under ASEAN Trade in Goods Agreement
Vessel's name/Aircraft etc.: BY TRUCK
☐ Preferential Treatment Not Given (Please state reason/s)
Port of Discharge: OTHER (VIETNAM)
..........................................................................................
Signature of Authorised Signatory of the Customs Authority of the Importing Country
5. Item number 6. Marks and numbers on 7. Number and type of packages, description of 8. Origin criterion 9. Gross weight or 10. Number and
packages goods (including quantity where appropriate and (see Overleaf other quantity and date of invoices
HS number of the importing country) Notes) FOB price where
RVC is applied
HS CODE: 76042910
HS CODE: 76042910
The undersigned hereby declares that the above details and statements are It is hereby certified, on the basis of control carried out, that the
correct; that all the goods were produced in declaration by the exporter is correct.
VIET NAM
(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
VIETNAM
(Importing country)
Accumulation De Minimis
Partial Cumulation
Page 2 / 4
ORIGINAL
Reference No. VN-VN 23/77/003109
1. Goods Consigned from (Exporter's business name, address, country)
3. Means of transport and route (as far as known) 4. For Official Use
Departure Date: 29/11/2023 ☐ Preferential Treatment Given Under ASEAN Trade in Goods Agreement
Vessel's name/Aircraft etc.: BY TRUCK
☐ Preferential Treatment Not Given (Please state reason/s)
Port of Discharge: OTHER (VIETNAM)
..........................................................................................
Signature of Authorised Signatory of the Customs Authority of the Importing Country
5. Item number 6. Marks and numbers on 7. Number and type of packages, description of 8. Origin criterion 9. Gross weight or 10. Number and
packages goods (including quantity where appropriate and (see Overleaf other quantity and date of invoices
HS number of the importing country) Notes) FOB price where
RVC is applied
HS CODE: 76042910
HS CODE: 76042910
The undersigned hereby declares that the above details and statements are It is hereby certified, on the basis of control carried out, that the
correct; that all the goods were produced in declaration by the exporter is correct.
VIET NAM
(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
VIETNAM
(Importing country)
Accumulation De Minimis
Partial Cumulation
Page 3 / 4
ORIGINAL
Reference No. VN-VN 23/77/003109
1. Goods Consigned from (Exporter's business name, address, country)
3. Means of transport and route (as far as known) 4. For Official Use
Departure Date: 29/11/2023 ☐ Preferential Treatment Given Under ASEAN Trade in Goods Agreement
Vessel's name/Aircraft etc.: BY TRUCK
☐ Preferential Treatment Not Given (Please state reason/s)
Port of Discharge: OTHER (VIETNAM)
..........................................................................................
Signature of Authorised Signatory of the Customs Authority of the Importing Country
5. Item number 6. Marks and numbers on 7. Number and type of packages, description of 8. Origin criterion 9. Gross weight or 10. Number and
packages goods (including quantity where appropriate and (see Overleaf other quantity and date of invoices
HS number of the importing country) Notes) FOB price where
RVC is applied
HS CODE: 76042910
The undersigned hereby declares that the above details and statements are It is hereby certified, on the basis of control carried out, that the
correct; that all the goods were produced in declaration by the exporter is correct.
VIET NAM
(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
VIETNAM
(Importing country)
Accumulation De Minimis
Partial Cumulation
Page 4 / 4