1.Goods consigned from：

（Exporter’s business name， address， country）

Reference No.

Issued in …………….

　　　　（Country）

2. Goods consigned to：

（Consignee’s name， address， country）

3.For Official use

4. Means of transport and route：

5.Tariff item number：

6. Marks and number of Packages：

7. Number

and kind of　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　 packages/

description

of goods：

8. Origin

criterion

（see notes

overleaf）

9. Gross

weight

or other

quantity：

10. Number and date of invoices：

11. Declaration by the exporter ：

The undersigned hereby declares that the above details and statements are correct： that all the goods were produced in

……………………………….

　　　　 （Country）

and that they comply with the origin requirements specified for these goods in the Asia-Pacific Trade Agreement for goods exported to

　……………………………….

　　（Importing Country）

　　……………………………….

　　Place and date， signature of authorized

　　Signatory

12. Certificate

　 It is hereby certified on the basis of control carried out， that the declaration by the exporter is correct.

…………………………………

　　Place and date， signature and Stamp of

　　Certifying Authority