1. Goods consigned from (Exporter's name, address, country) Reference No.

CV SNACKINDO MAKMUR THE AGREEMENT ON COMPREHENSIVE ECONOMIC

JALAN BOULEVARD BARAT RAYA,
KOKAN KTC BLOK G NOMOR 68-69 KEL. KELAPA GADING PARTNERSHIP AMONG MEMBER STATES OF THE
INDONESIA
ASSOCIATION OF SOUTHEAST ASIAN NATIONS AND JAPAN

(AJCEP AGREEMENT)

2. Goods consigned to(Importer's/Consignee's name,address,country)

CERTIFICATE OF ORIGIN
UNITED GOURMET CO., LTD.
FORM AJ
18-4, SAKURAGAOKA, SHIBUYA-KU,
TOKYO 150-0031, JAPAN INDONESIA
Issued in _______________

(Country)

See Notes Overleaf

3. Means of transport and route (as far as known) 4. For Official Use
Shipment date
NOVEMBER 20, 2022
Preferential Treatment Given Under AJCEP Agreement

Vessel's name/Aircraft etc.

OOCL JAKARTA V.150N
Preferential Treatment Not Given (Please State
reason/s)
Port of discharge
TOKYO, JAPAN
.............................................................................................................

Signature of Authorised Signatory of the Importing Country

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

1 286 CTNS OF CTC 1,821.820 KGM 007/UG/2022

KERIPIK TEMPE JERUK PURUT (200 G X (ONE THOUSAND NOVEMBER
28)(SOY BEAN CRISPS WITH KAFFIR EIGHT HUNDRED 17, 2022
LIMELEAVES) AND TWENTY-ONE
HS CODE : 2008.19 POINT EIGHT
HUNDRED AND
TWENTY)

2 234 CTNS OF CTC 1,490.580 KGM 007/UG/2022

KERIPIK TEMPE PEDAS (200 G X 28)(SPICY (ONE THOUSAND NOVEMBER
SOY BEAN CRISPS) FOUR HUNDRED 17, 2022
HS CODE : 2008.19 AND NINETY
POINT FIVE
HUNDRED AND
EIGHTY)

11. Declaration by exporter 12. Certification

The undersigned hereby declares that the above It is hereby certified, on the basis of control carried
details and statement are correct; that all the goods out, that the declaration by the exporter is correct.
were produced in
INDONESIA ISSUING OFFICE IN KABUPATEN BOGOR
...........................................................................................
(Country)

and that they comply with the requirements specified for these
goods in the AJCEP Agreement for the goods exported to

JAPAN
...........................................................................................
(Importing Country)
HENDRA NOVIANTO GUNAWAN
CV SNACKINDO MAKMUR
JAKARTA UTARA, CIBINONG,
....................................................................................... .......................................................................................
Place and date, name, signature and company of authorised Place and date, signature and stamp of certifying authority
signatory

13. V Third-Country Invoicing Back-to-Back CO Issued Retroactively

Page 1 / 3
1. Goods consigned from (Exporter's name, address, country) Reference No.
CV SNACKINDO MAKMUR THE AGREEMENT ON COMPREHENSIVE ECONOMIC
JALAN BOULEVARD BARAT RAYA,
KOKAN KTC BLOK G NOMOR 68-69 KEL. KELAPA GADING PARTNERSHIP AMONG MEMBER STATES OF THE
INDONESIA
ASSOCIATION OF SOUTHEAST ASIAN NATIONS AND JAPAN

(AJCEP AGREEMENT)

2. Goods consigned to(Importer's/Consignee's name,address,country)

CERTIFICATE OF ORIGIN
UNITED GOURMET CO., LTD.
FORM AJ
18-4, SAKURAGAOKA, SHIBUYA-KU,
TOKYO 150-0031, JAPAN INDONESIA
Issued in _______________

(Country)

See Notes Overleaf

3. Means of transport and route (as far as known) 4. For Official Use
Shipment date
NOVEMBER 20, 2022
Preferential Treatment Given Under AJCEP Agreement

Vessel's name/Aircraft etc.

OOCL JAKARTA V.150N
Preferential Treatment Not Given (Please State
reason/s)
Port of discharge
TOKYO, JAPAN
.............................................................................................................

Signature of Authorised Signatory of the Importing Country

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

3 104 CTNS OF WO 355.680 KGM 007/UG/2022

KERIPIK PISANG SALE LIDAH (130 G X (THREE HUNDRED NOVEMBER
24)(BANANA CRISPS) AND FIFTY-FIVE 17, 2022
HS CODE : 2008.99 POINT SIX
HUNDRED AND
EIGHTY)

11. Declaration by exporter 12. Certification

The undersigned hereby declares that the above It is hereby certified, on the basis of control carried
details and statement are correct; that all the goods out, that the declaration by the exporter is correct.
were produced in
INDONESIA ISSUING OFFICE IN KABUPATEN BOGOR
...........................................................................................
(Country)

and that they comply with the requirements specified for these
goods in the AJCEP Agreement for the goods exported to

JAPAN
...........................................................................................
(Importing Country)
HENDRA NOVIANTO GUNAWAN
CV SNACKINDO MAKMUR
JAKARTA UTARA, CIBINONG,
....................................................................................... .......................................................................................
Place and date, name, signature and company of authorised Place and date, signature and stamp of certifying authority
signatory

13. V Third-Country Invoicing Back-to-Back CO Issued Retroactively

Page 2 / 3
1. Goods consigned from (Exporter's name, address, country) Reference No.
CV SNACKINDO MAKMUR THE AGREEMENT ON COMPREHENSIVE ECONOMIC
JALAN BOULEVARD BARAT RAYA,
KOKAN KTC BLOK G NOMOR 68-69 KEL. KELAPA GADING PARTNERSHIP AMONG MEMBER STATES OF THE
INDONESIA
ASSOCIATION OF SOUTHEAST ASIAN NATIONS AND JAPAN

(AJCEP AGREEMENT)

2. Goods consigned to(Importer's/Consignee's name,address,country)

CERTIFICATE OF ORIGIN
UNITED GOURMET CO., LTD.
FORM AJ
18-4, SAKURAGAOKA, SHIBUYA-KU,
TOKYO 150-0031, JAPAN INDONESIA
Issued in _______________

(Country)

See Notes Overleaf

3. Means of transport and route (as far as known) 4. For Official Use
Shipment date
NOVEMBER 20, 2022
Preferential Treatment Given Under AJCEP Agreement

Vessel's name/Aircraft etc.

OOCL JAKARTA V.150N
Preferential Treatment Not Given (Please State
reason/s)
Port of discharge
TOKYO, JAPAN
.............................................................................................................

Signature of Authorised Signatory of the Importing Country

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

4 78 CTNS OF WO 489.840 KGM 007/UG/2022

LAPIS LEGIT (300 G X 20)(ORIGINAL LAYER (FOUR HUNDRED NOVEMBER
CAKE) AND EIGHTY-NINE 17, 2022
HS CODE : 1905.90 POINT EIGHT
HUNDRED AND
FORTY)
THE GOODS WILL BE SUBJECT TO
ANOTHER INVOICE TO BE ISSUED IN A
NON-PARTY INVOICE. ISSUER: HILL SUN
PTE LTD. 60 PAYA LEBAR ROAD#4-38 PAYA
LEBAR SQUARE, SINGAPORE 409051
SINGAPORE

11. Declaration by exporter 12. Certification

The undersigned hereby declares that the above It is hereby certified, on the basis of control carried
details and statement are correct; that all the goods out, that the declaration by the exporter is correct.
were produced in
INDONESIA ISSUING OFFICE IN KABUPATEN BOGOR
...........................................................................................
(Country)

and that they comply with the requirements specified for these
goods in the AJCEP Agreement for the goods exported to

JAPAN
...........................................................................................
(Importing Country)
HENDRA NOVIANTO GUNAWAN
CV SNACKINDO MAKMUR
JAKARTA UTARA, CIBINONG,
....................................................................................... .......................................................................................
Place and date, name, signature and company of authorised Place and date, signature and stamp of certifying authority
signatory

13. V Third-Country Invoicing Back-to-Back CO Issued Retroactively

Page 3 / 3