CO FROM D - Sample

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1.Goods consigned from (Exporter's business name, Reference No.

address, country) ASEAN TRADE IN GOODS AGREEMENT/


ASEAN INDUSTRIAL COOPERATION SCHEME
CERTIFICATE OF ORIGIN
(Combined Declaration and Certificate)
FORM D
Issued in ___Malaysia___________
2. Goods consigned to (Consignee's name, address, country) (Country)
(See Overleaf Notes)

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

Departure Date:
□ Preferential Treatment Given Under ASEAN Trade
in Goods Agreement

Vessel‘s name/Aircraft, etc. __________________________________________


□ Preferential Treatment Given Under ASEAN
Industrial Cooperation Scheme
Port of discharge
__________________________________________

Preferential Treatment Not Given
(Please state reason/s)
..................................................................................
Signature of Authorised Signatory of the
Importing Country
5. Item 6. Marks and 7. Number and type of packages, description of goods 8. Origin 9. Gross weight 10. Number and date of
number numbers of (including quantity where appropriate and HS criteria or other quantity Invoices
packages number of the importing Party) (see and value (FOB)
Overleaf
Notes)

11. Declaration by the exporter 12. Certification


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

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

and that they comply with the origin requirements specified


for these goods in the ASEAN Trade in Goods Agreement
for the goods exported to

................................................................................

............................................................. Place and date, signature and stamp of certifying authority


(Importing Country)

........................................................
Place and date, signature of authorised signatory
13.
□ Third - Country Invoicing □ Exhibition
□ Accumulation □ De Minimis
□ Back-to-Back CO □ Issued Retroactively
□ Partial Cumulation

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