Certificate of Origin Compliance

Exporter Details

Name
Address
Country

Consignee Details

Name
Address
Country

Shipment Information

Invoice Number
Date of Shipment
Means of Transport
Port of Loading
Port of Discharge

Goods Description

No.	Description of Goods	HS Code	Quantity	Origin Criteria

Declaration

I hereby declare that the goods described above are of origin and that the information provided above is true and correct to the best of my knowledge.

Date

Authorized Signature & Company Stamp