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3. Means of transport and route (as far as known)
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4. For Official Use
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Departure date
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Preferential Treatment Given Under ASEAN
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Common Effective Preferential Tariff Scheme
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Vessel's name/Aircraft etc.
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Preferential Treatment Given Under ASEAN
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Industrial Cooperation Scheme
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Preferential Treatment Not Given (Please
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Port of Discharge
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state reason/s)
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..................................................................................
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Signature of Authorised Signatory of the Importing
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Country
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11. Declaration by the exporter
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12. Certification
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The undersigned hereby declares that the above
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It is hereby certified, on the basis of control
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details and statement are correct; that all the goods
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carried out, that the declaration by the
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were produced in
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exporter is correct.
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.............................................................
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(Country)
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and that they comply with the origin requirements
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specified for these goods in the ASEAN Common
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Effective Preferential Tariff Scheme for the goods
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exported to
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.............................................................
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(Importing Country)
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.............................................................
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................................................................................
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Place and date, signature of
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Place and date, signature and stamp of
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authorised signatory
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certifying authority
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13
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□ Third-Country Invoicing
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□ Exibition
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□ Accumulation
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□ De Minimis
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□ Back-to-Back CO
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□ Issued Retroactively
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□ Partial Cumulation
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