69923800108

1. Products consigned from (Exporter's business name, address, country) Reference No. 0008371/KTG/2018
PD. AQUARAMA KARYALESTARI
JL. TAHUMBAN DESA TOHO HILIR KEC.TOHO ASEAN-CHINA FREE TRADE AREA
KAB.MEMPAWAH KALIMANTAN BARAT PREFERENTIAL TARIFF
INDONESIA
CERTIFICATE OF ORIGIN
(Combined Declaration and Certificate)
2. Products consigned to (Consignee's name, address, country)
FORM E
XIAMEN YINGLONG ORNAMENTAL FISH IMPORTS & EXPORTS
CO.LTD,
NO.90 SHANGXIANG DAGONG KOULI, BINGZHOU Issued in INDONESIA
VILLAGE, XIKE TOWN, TONGAN DISTRICT, XIAMEN
FUJIAN 361100,CHINA
See Overleaf Notes

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

Departure Date MARCH 10, 2018 Preferential Treatment Given

Vessel's name/Aircraft etc. BY AIR Preferential Treatment Not Given (Please state reason/s)

.................................................................................................................
Port of Discharge XIAMEN
Signature of Authorised Signatory of the Importing Party

5. Item 6. Marks and 7. Number and type of packages, 8. Origin criteria 9. Gross weight 10. Number and
number numbers of description of products (including (see Overleaf or other quantity date of
packages quantity where appropriate and Notes) and value (FOB) invoices
HS number of the importing Party)

1 ASIAN AROWANA (190) "WO" USD 4,750 001/III/AKL/2018

(SCLEROPAGES FORMOSUS) MARCH 7, 2018
SIZE : 18 - 25 CM
HS : 0301.11.00.10

2 ASIAN AROWANA (10) "WO" USD 400 001/III/AKL/2018

(SCLEROPAGES FORMOSUS) MARCH 7, 2018
SIZE : 26 - 35 CM
HS : 0301.11.00.10

TOTAL : 13 BOX

11. Declaration by the exporter 12. Certification

The undersigned hereby declares that the above details and statement are It is hereby certified, on the basis of control carried out, that the declaration by
correct; that all the products were produced in the exporter is correct

INDONESIA MUNICIPALITY OFFICE IN TANGERANG

.....................................................................
(Country)

and that they comply with the origin requirements specified for these
products in the Rules of Origin for the ACFTA for the products exported to

CHINA
.....................................................................
(Importing Country)

PONTIANAK, MARCH 8, 2018

..........................................................................................................
Place and date, signature of authorised signatory

OKE SULENDRO SETYO RACHMAN

13.
Issued Retroactively Exhibition TANGERANG, MARCH 8, 2018
.............................................................................................................
Movement Certificate Third Party Invoicing Place and date, signature and stamp of certifying authority

Page 1 / 1